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ALEXIUS  McGLANNAN,  M.  dJ 


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Columbia  BSnibers^itp 

in  tlje  Citp  of  JgetD  gorb 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons - 


http://www.archive.org/details/manualofsurgicalOOberr 


SURGICAL  DIAGNOSIS 


By  the  same  Author 

DISEASES   OF  THE  THYROID 
GLAND 

AND  THEIR  SURGICAL  TREATMENT 

With  121  Illustrations 


A  MANUAL 


OF 


SURGICAL  DIAGNOSIS 


BY 


JAMES  BERRY,  B.S.,  F.R.C.S. 

SURGEON   TO,   AND  LECTURER  ON  SURGERY  AT,   THE  ROYAL  FREE  HOSPITAL, 

FORMERLY  SURGICAL  REGISTRAR  AND  DEMONSTRATOR  OF  ANATOMY 

OP  OPERATIVE  SURGERY  AND  OF  PRACTICAL  SURGERY 

AT  ST.  BARTHOLOMEW'S  HOSPITAL 


CATHQkIC    Uj^ERSi 


PHILADELPHIA 

P.    BLAKISTON'S    SON    &    CO. 

1012  WALNUT   STKEET 
1904 


Printed  by  Ballantyne,  Hanson  S^  Co. 
London  &'  Edinburgh 


TO 
SIR   THOMAS   SMITH,  BAHT.,  K.C.V.O. 

IN    GRATEFUL    AND    AFFECTIONATE    RECOGNITION 
OF    ALL    THAT    HE    HAS    TAUGHT    ME 


PEEFACE. 

This  little  book  is  intended  mainly  for  dressers  and 
junior  practitioners,  and  is  the  outcome  of  more  than 
twenty  years  of  practical  experience  in  the  teaching  of 
clinical  surgery.  Surgical  diagnosis  is  so  vast  a  subject, 
and  so  closely  connected  with  pathology  and  other 
branches  of  surgery  and  medicine,  that  it  is  difficult  to 
write  of  it  as  a  separate  entity.  It  is  a  subject  with  no 
beginning  and  no  end,  so  intricate  and  far  reaching  are 
the  questions  involved  in  surgical  diagnosis.  It  is 
hoped,  however,  that  a  book  which  does  not  attempt  to 
deal  fully  with  every  detail  of  surgical  diagnosis,  but 
concerns  itself  rather  with  the  principles  involved  and 
with  the  methods  of  examination  that  ought  to  be 
adopted  in  individual  cases,  may  serve  a  useful 
purpose. 

Throughout  the  book  the  attempt  has  been  made  to 
deal  mainly  with  diseases  and  injuries  that  are  common, 
and  therefore  of  most  importance  to  the  student.  I 
have  endeavoured  to  lay  stress  upon  what  I  have  most 
often  seen  and  experienced  and  believe  to  be  of  value, 
and  have  endeavoured  to  omit  or  to  touch  lightly  upon 
what  I  have  found  to  be  uncommon. 

I  am  aware  that  in  doing  this  I  shall  be  accused  of 
having  left  out  a  good  deal  that  I  ought  to  have  put  in. 


Vlll  PREFACE. 

Doubtless  there  will  be  much  truth  in  the  accusation. 
I  can  only  reply  that  I  have  tried  to  write  down  that 
which  seemed  to  me  to  be  of  most  importance. 

To  my  friends  Mr.  E.  W.  Eoughton  and  Dr.  Florence 
Willey  I  am  indebted  for  many  valuable  suggestions 
and  for  revision  of  the  proof-sheets.  I  have  also  to 
thank  Miss  Lilian  Nay]  or  for  the  care  with  which  she 
has  prepared  the  index. 

21  WlMPOLE    STEEET,  W. 
April  1904. 


CONTENTS. 


PAGE 

I 


PART    I. 

CHAP. 

I.  INTEODUCTOEY 

II.   SURGICAL     "  HISTORY  "     AND     HOW    IT    SHOULD     BE 

TAKEN 12 

III.   PHYSICAL    EXAMINATION,    AND    HOW    TO     MAKE    IT. 

METHODS   OP  EXAMINATION  ....  20 


PART    II. 
DISEASES. 


IV,  DISEASES    OP   THE   NOSE,  NASO-PHARYNX  AND   ACGES 

SORY  SINUSES 

V.  DISEASES   OP   THE   EAR 

VI.   INABILITY   TO   OPEN   THE  MOUTH 
VII.  DISEASES     OP     THE     TONOUE     AND     FLOOR    OP     THE 

MOUTH   

VIII.   DISEASES   OP   THE   PALATE  .... 

IX.  DYSPHAGIA 

X.  DISEASES   OP   THE  LARYNX 
XI.  DISEASES   OP   THE   THYROID   GLAND    . 
XII.  DISEASES   OP  THE   BREAST  ..... 
XIII.   DISEASES     OP     THE     ABDOMEN.       DIAGNOSIS     OP 

ABDOMINAL   SWELLING 

XIV.   DISEASES   OP  THE    ABDOMEN   {continued).      ENLARGE 
MENT   OP  A  SINGLE   ORGAN   . 


AN 


40 

53 
70 

73 
79 
81 
88 
104 
115 

125 

145 


CONTEXTS. 


CHAP. 

XV.  ABD03II:N'AL  paix       .... 

XVI.  IXTESTIXAL    OBSTErCTIOX 

XVII.  HEEXIA 

XVIII.  DIAG-XOSIS   OF   GALL-STOX'ES      . 

XIX.  DISEASES   OF   THE   EECTUM   AXD   AXUS 

XX.  DISEASES   OF   THE   UETXAEY  OEG-AXS 

XXI.  PYUEIA   AXD    H-EMATUEIA 

XXII.  DISEASES    OF    THE    SCE0TU3I    AXD    ITS    COXTEXT- 

XXIII.  DISEASES   OF  BOXE 

XXIV.  DISEASES   OF  JOIXTS  ... 

XXV.  DISEASES   OF    THE   SPIXE 

XXVI.  DIAGXOSIS   OF   EXLAE&ED   LYMPHATIC    GLAXDS 

XXVII.  DIAG-XOSIS    OF    AXEUEISM 


PAGE 

167 
178 

1 88 

195 
206 
221 
230 
238 
246 
258 
271 
276 


PART   III. 
INJURIES. 


XXVIII.    EXAJMIXATIOX     AXD     DIAGXOSIS     OF     IXJUEIES     IX 

GEXEEAL  

XXIX.    IXJUEIES    TO    THE    HEAD     .... 
XXX.    IXJUEIES    TO    THE   XECK     .... 
XXXI.    IXJUEIES    TO    THE   CHEST  .... 
XXXII.    IXJUEIES   TO   THE   ABDOMEX       . 

XXXIII.  IXJUEIES   TO    THE   PELVIS 

XXXIV.  IXJUEIES   TO   THE   SPIXE     .... 
XXXV.    IXJUEIES   TO   THE   LI3IBS  .... 

ISTDEX  ....... 


2S1 
283 
290 

293 

299 

309 
313 
318 
325 


PART  I. 

SUEGICAL  DIAGNOSIS. 

CHAPTER  I. 

INTRODUCTORY. 

The  art  of  surgical  diagnosis  consists  in  eliciting,  by- 
questions  and  by  direct  physical  examination,  as  much 
information  as  possible  about  the  case  that  is  the 
object  of  diagnosis  ;  in  examining  the  information  thus 
obtained  ;  in  reasoning  upon  it ;  and  in  deducing  a 
correct  conclusion  therefrom. 

In  order  that  the  conclusion  or  diagnosis  be  correct, 
it  is  desirable  that  the  information  obtained  should  be 
as  full  and  complete  as  possible,  and  that  the  reasoning 
be  correct. 

It  is  obvious  that  the  correctness  of  the  diagnosis 
will  depend : 

i.  Upon  the  fulness  and  the  accuracy  of  the  infor- 
mation obtained. 
ii.  Upon  the  experience  and  knowledge  of  surgery 
possessed  by  the  surgeon,  which  enable  him  to 
reason  correctly  upon  the  information  he  has 
obtained. 
Accurate  information  about  the  various  points  of  the 

A 


2  SURGICAL    DIAGNOSIS. 

case  will  not  suffice  for  a  correct  and  reliable  diagnosis 
unless  a  knowledge  of  surgery,  and  especially  of 
suro-ical  pathology,  as  well  as  a  certain  amount  of 
practical  experience,  be  possessed  by  tlie  diagnostician. 
On  the  other  hand,  it  is  essential  that  the  premisses 
upon  which  the  conclusion  is  based  should  be 
correct,  if  a  correct  interpretation  is  to  be  placed  upon 
them. 

Incorrect  diagnosis  may  arise  either  from  incomplete 
or  inaccurate  premisses,  or  from  incorrect  deduction 
therefrom. 

Surgical  diagnosis  ought  not  to  consist,  as  some 
students  seem  to  imagine  that  it  does,  in  the  mere 
fittino-  of  a  name  to  a  diseased  condition.  It  should  be 
much  more  than  this.  It  should  aim  at  ascertaining 
as  exactly  as  possible  in  what  respect,  and  to  what 
extent,  the  patient's  condition  deviates  froii;i  that  of 
perfect  health.  In  other  words,  it  should  comprise,  not 
only  the  nomenclature  of  the  disease,  but  also  the 
degrree  and  extent  of  that  disease. 

The  diagnostician  has  two  main  sources  of  informa- 
tion upon  which  to  found  his  diagnosis. 

He  ascertains  from  the  patient,  or  from  others,  the 
liistory  of  the  various  ailments  or  symptoms  which 
have  been  noticed.  He  ascertains,  by  direct  physical 
examination,  to  what  extent  the  condition  of  the 
bodv  before  him  differs  from  the  normal  condition  of  a 
body  of  the  same  age  and  sex. 

Bv  putting  together  all  the  pieces  of  information 
obtained  from  these  two  sources,  by  reasoning  about 
them  and  by  exercising  his  judgment,  he  endeavours 
to  arrive,  if  possible,  at  a  diagnosis  of  the  diseased 
condition. 


INTRODUCTORY.  3 

Sometimes  the  one  and  sometimes  the  other  of  these 
two  main  sources  of  information  is  the  more  important. 
As  a  rule  neither  should  be  completely  ignored. 

Thus,  in  the  case  of  an  otherwise  healthy  person  who 
has  a  laro-e,  soft,  lobulated  tumour  in  the  subcutaneous 
tissue  over  the  shoulder,  the  physical  characters  alone 
are  usually  sufficient  for  a  diagnosis  of  fatty  tumour. 
The  history  is  comparatively  unimportant,  and  would 
probably  merely  refer  to  the  duration  of  the  tumour 
and  to  any  other  ailments  of  which  the  patient  may 
also  be  the  subject. 

Conversely,  a  history  of  repeated  severe  attacks  of 
excruciating  pain  in  the  area  of  distribution  of  some 
portion  of  the  fifth  nerve  may  be  sufficient  for  the 
diagnosis  of  epileptiform  neuralgia,  even  though  the 
patient  may  present  no  physical  sign  of  disease. 

Much  caution  should,  however,  be  exercised  before 
making  a  diagnosis  upon  history  alone.  Physical 
signs  of  disease  which  the  surgeon  can  himself  observe 
are  as  a  rule  much  more  im]3ortant  to  him  than  mere 
history,  for  which  he  has  to  depend  upon  what  is  told 
him  by  others. 

If  history  and  physical  examination  appear  to  be 
contradictory,  more  stress  should,  as  a  rule,  be  laid 
upon  the  latter  than  upon  the  former. 

Importance  of  Care  and  Thoroughness  in 
Conducting  the  Examination. 

The  examination,  both  oral  and  physical,  should  be 
conducted  carefullv,  and  should  be  as  thorouo-h  as 
circumstances  allow. 

It  is  all  very  well  for  a  surgeon  of  considerable  age 


4  SURGICAL   DIAGNOSIS. 

and  vast  experience  to  glance  at  a  patient,  just  lay  Ms 
hands  on  the  affected  part,  perhaps  ask  one  or  two 
questions,  and  then  deliver  himself  of  a  diagnosis. 
For  such  surgeons  this  book  is  not  intended,  although 
even  such  as  they  will  sometimes  make  mistakes  if 
they  practise  too  frequently  such  rapid  and  cursory 
examinations.  For  the  less  experienced  practitioner 
it  cannot  too  earnestly  be  laid  down  that  care  and 
thoroughness  in  examination  are  all  important.  "  Snap- 
shot "  diagnoses,  although  sometimes  impressive  to 
the  onlooker,  carry  with  them  the  risk  of  serious  error, 
and  are  not  to  be  recommended.  More  mistakes  in 
surgical  diagnosis  have  arisen  from  carelessness  and 
over  confidence  than  from  actual  want  of  knowledge  on 
the  part  of  the  surgeon. 

In  conducting  his  examination  of  the  patient  the 
surgeon  should  not  confine  his  attention  exclusively  to 
that  particular  part  of  the  body  of  which  the  patient 
complains.  Although  this  is  the  part  which  first  and 
chiefly  engages  his  attention,  he  should  not  omit  to 
examine  other  parts  as  well.  If  the  affection  is  a 
unilateral  one,  he  should  carefully  examine  the  corres- 
ponding part  on  the  opposite  side  of  the  body,  com- 
paring it  with  the  affected  region. 

If  the  case  be  an  obscure  one,  a  very  thorough  and 
minute  examination  of  many  parts  may  become 
necessary. 

It  should  not  be  forgotten  that  a  patient  may  be 
suffering  simultaneously  from  two  or  more  diseases. 
The  one  which  is  most  obvious  and  most  easily  dis- 
covered is  by  no  means  necessarily  the  most  important. 

Thus  a  patient  may  present  himself  with  the 
symptom   of   piles,  but    have    also    a    carcinomatous 


INTRODUCTORY.  5 

stricture  of  the  rectum.  A  woruan  with  a  femoral 
hernia  may  be  suffering  from  internal  strangulation  of 
some  other  portion  of  the  bowel. 

A  patient  with  an  adenoma  of  the  breast  may  have 
enlarged  axillary  glands  due  to  old  tuberculous  or 
other  disease,  and  so  on. 

"  Have  you,  or  have  you  ever  had,  any- 
thing: else  the  matter  with  you?"  is  a  useful 
question,  the  answer  to  which  may  perhaps,  by  reveal- 
ing some  obscure  or  unnoticed  feature  in  the  condition 
of  the  patient  or  in  the  history  of  the  case,  throw  an 
entirely  new  light  upon  the  problem  of  diagnosis,  and 
may  be  of  the  utmost  importance. 

This  question  is  often  useful  w^hen  the  investigator 
begins  to  feel  that  he  is  being  puzzled  by  the  case,  or 
is  uncertain  as  to  its  exact  nature. 

A  patient  was  admitted  into  hospital  on  account  of  a 
chronic  ulcer  of  the  leg.  The  dresser  made  excellent  notes 
about  the  ulcer,  but  found  himself  wholly  unable  to  give  any 
diagnosis  as  to  its  nature,  since  the  diagnostic  features  of  the 
ulcer  were  not  in  themselves  sufficiently  characteristic.  A 
more  complete  examination  revealed,  on  the  patient's  back, 
a  circular,  deeply  excavated  ulcer ;  there  were  also,  in 
various  other  parts  of  the  body,  round  depressed  scars  of 
healed  ulcers.  Also  careful  examination  of  the  pupils 
showed  considerable  irregularity  in  one  of  them,  and  be- 
tokened a  former  attack  of  iritis. 

It  was  then  clear  that  the  patient  was  suffering  from 
tertiary  syphilis,  and  much  light  was  thrown  upon  the 
nature  of  the  ulcer  of  the  leg. 

A  boy  was  admitted  on  account  of  a  swelling  of  one 
knee-joint,  which  had  supervened,  apparently  sponta- 
neously, a  few  days  previously.  It  was  obvious  that  the 
joint  was  full  of  fluid,  but  the  nature  of   the  fluid   was  not 


O  SURGICAL   DIAGNOSIS. 

apparent  until  cross-examination  elicited  the  information 
that  on  several  previous  occasions  he  had  bled  severely  after 
the  extraction  of  teeth,  that  he  had  also  suffered  from 
haemorrhage  from  the  rectum  and  that  other  members  of  his 
family  had  also  shown  a  marked  tendency  to  haemorrhage. 
The  swelling  of  the  knee-joint  was  thus  suspected  to  be  due 
to  haemophilia,  and  closer  examination  of  the  joint  showed  a 
very  slight  discoloration,  which  confirmed  the  diagnosis. 

Excessive  Examination. 

In  the  case  of  patients  who  are  acutely  ill,  prolonged 
and  thorough  examinations  are  often  inadvisable.  How- 
ever desirable  from  the  point  of  view  of  exact  diagnosis, 
they  may  cause  much  distress  and  even  harm  to  the 
patient,  from  exposure,  pain,  or  fatigue. 

It  may  be  better  to  remain  in  ignorance  about  certain 
points  necessary  for  a  complete  diagnosis,  rather  than 
run  the  risk  of  doing  harm  to  the  patient  by  thorough 
investigation  of  these  points. 

Unless  some  important  point  of  treatment  depends 
upon  the  exactness  of  the  diagnosis,  it  is  often  better, 
at  any  rate  for  the  time,  to  defer  making  that  thorough 
examination  without  which  complete  diagnosis  may  be 
impossible. 

Probability  as  an  Element  in  Diagnosis. 

Students  often  show  a  tendency  to  diagnose  rarities 
of  which  they  have  read  in  books,  but  which  they 
have  never  actually  seen.  The  experienced  practitioner 
will  hesitate  to  do  so  until  he  has  fully  considered  the 
possibility  of  the  existence  of  some  commoner  affection. 

This  is  frequently  shown,  for  example,  in  the  diag- 


INTRODUCTORY.  7 

nosis  between  chronic  inflammatory  affections  of  bone, 
which  are  common,  and  malignant  tumours  of  the  same 
part,  which  are  distinctly  less  common. 

The  diagnosis  of  a  rare  disease  should  not  be  made 
unless  its  features  are  characteristic  and  unmistakable, 
or  until  the  possibility  of  its  being  some  more  common 
disease  has  been  carefully  considered  and  excluded. 

If  an  example  of  some  rare  disease  has  recently  been 
under  his  observation,  the  surgeon,  when  he  meets  with 
a  second  case  of  apparently  similar  nature,  should  be 
on  his  guard  against  jumping  hurriedly  to  the  conclu- 
sion that  this  also  is  an  example  of  the  same  disease. 
It  is  probable  that  it  will  not  be  the  same  disease,  and 
he  should  examine  most  carefully  before  pronouncing  it 
to  be  of  the  same  rare  nature  as  the  first. 

The  age  and  sex  of  the  patient  are  important  elements 
in  this  question  of  probability. 

A  disease  that  is  common  in  the  male  subject  may 
be  rare  in  the  female,  and  vice  versa.  Thus  the 
symptoms  of  perforative  peritonitis  at  the  upper  part 
of  the  abdomen  in  the  case  of  an  ansemic  young  woman 
are  very  suggestive  of  a  perforated  gastric  ulcer. 
Similar  symptoms  in  a  young  man  would  be  more  likely 
to  indicate  a  perforated  duodenal  ulcer. 

A  disease  that  is  frequently  seen  in  the  young  may 
be  uncommon  or  unknown  in  an  older  person,  and 
vice  versa.  Thus,  a  history  of  frequent  slight  haemor- 
rhage from  the  rectum  in  the  case  of  a  young  child 
would  suggest  a  polypus ;  the  same  symptom  in  an 
adult  would  be  more  likely  to  indicate  piles,  or  some 
form  of  ulceration  of  the  rectum. 

Chronic  and  severe  intestinal  obstruction  for  which 
no  definite  cause  can  be  discovered  is  exceedingly  likely 


8  SURGICAL    DIAGNOSIS. 

to  be  due,  ia  the  case  of  an  elderly  person,  to  a  carci- 
nomatous tumour  of  the  large  intestine.  In  the  case  of 
a  child,  such  a  diagnosis  would  be  in  the  highest  degree 
improbable,  whereas  bands  of  adhesion,  due  to  some  old 
inflammatory  trouble,  or  some  congenital  aflfection, 
would  be  a  much  more  likely  cause. 

The  surgeon  should  always  endeavour  to  make  his 
diagnosis  as  complete  as  possible.  Sometimes, 
however,  a  complete  diagnosis  may,  owing  to  lack  of 
sufficient  evidence,  be  impossible.  In  such  a  case  the 
surgeon  may  be  able  to  make  a  partial  diagnosis.  He 
should  always  aim  at  making  his  diagnosis  as  accurate 
and  complete  as  he  can. 

Diagnosis  is  usually  but  the  first  step  towards  prog- 
nosis and  treatment.  Sometimes  these  latter  may  be 
sufficiently  evident  even  in  the  absence  of  the  former 
in  its  complete  form. 

Thus,  a  patient  may  be  suffering  from  acute  symptoms 
of  severe  intestinal  obstruction,  which  may  obviously 
demand  the  surgical  operation  of  abdominal  section, 
although  the  precise  nature  of  the  obstruction  may  be 
problematical  until  the  abdomen  has  been  opened. 

The  diagnosis  of  a  tumour  (using  the  word  in  its 
widest  sense  of  a  swelling)  generally  involves  an  answer 
to  two  distinct  questions. 

1.  Where  is  the  lump  ? — i.e.,  in  what  anatomical 
structure  is  it  situated  ? 

2.  What  is  the  lump  ? — i.e.,  what  is  its  exact 
nature,  is  it  inflammatory,  new  growth,  &c.  ? 

Frequently  the  answer  to  one  of  these  questions  may 
easily  and  readily  be  given,  while  the  answer  to  the 
other  is  difficult  or  impossible. 

Eor  instance,  a  small  hard  lump  in  the  region  of  one 


INTRODUCTORY.  9 

lobe  of  the  thyroid  gland,  and  moving  freely  with  the 
larynx  and  trachea,  may  without  much  fear  of  error  be 
pronounced  to  be  a  swelling  of  the  thyroid  gland.  It 
may,  nevertheless,  be  a  matter  of  considerable  diffi- 
culty to  decide  whether  this  is  a  solid  adenoma,  a  tense 
cyst,  or  a  malignant  tumour  in  an  early  stage. 

A  swelling  in  the  scrotum  may  obviously  be  of  the 
testis,  but  it  may  be  very  difficult  or  impossible  to 
pronounce  definitely  whether  it  is  inflammatory  or 
malignant. 

Conversely,  a  pulsating  swelling  deeply  seated  at  the 
root  of  the  neck  and  behind  the  sternum  may  obviously 
be  an  aneurism,  and  yet  it  may  be  very  difficult  or 
impossible  to  say  whether  it  springs  from  the  arch  of 
the  aorta  or  from  the  innominate  artery. 

A  hard  and  somewhat  nodular  tumour  deeply  seated 
in  the  abdomen  of  an  elderly  patient  who  had  recently 
lost  much  weight  and  strength  without  apparent  cause 
may  be  clearly  malignant,  while  the  exact  anatomical 
situation  of  the  growth  may  be  a  matter  of  much 
doubt. 

Diagnosis  by  Exclusion. 

In  a  difficult  case  in  which  the  history  and  physical 
signs  do  not  point  clearly  to  a  definite  diagnosis,  the 
surgeon  may  find  it  useful  to  endeavour  to  make  a 
diagnosis  by  the  method  of  exclusion.  He  passes 
rapidly  before  his  mind  all  the  possible  diseases,  or 
groups  of  diseases,  of  which  the  case  before  him  may 
be  an  example.  By  eliminating  first  one  then  another 
and  so  on,  he  gradually  narrows  the  field  of  diagnosis 
more  and  more  until    eventually  he  may  be  able  to 


10 


SURGICAL   DIAGNOSIS. 


arrive  at  a  conclusion  as  to  the  true  nature  of  the 
affection  before  him. 

By  this  method  lie  is  less  likely  to  overlook  some 
possible  diagnosis  which  had  perhaps  not  hitherto 
occurred  to  his  mind. 

In  proceeding  to  make  a  diagnosis  by  exclusion, 
some  such  classification  of  diseases  as  the  following 
may  be  found  useful.  It  may  be  modified,  extended  or 
altered  according  to  individual  taste  : 

1.  Congenital  malformations. 

2.  Atrophy. 


3. 
4- 


-e.g.,  tubercle, 
abscess, 


Hypertrophy. 
Inflammation. 

(a)  Acute. 

(h)  Chronic. 

(c)  Due  to  specific  processes 
syphilis,  rheumatism. 

(d)  Results    of    inflammation — e.g., 
ulcer,  scar,  &c. 

'  Extravasations — e.g.,  of  blood. 
Accumulations — e.g.,   of  fluids    in    ducts     or 

closed  cavities. 
Concretions — e.g.^  calculi,  faecal   concretions, 

&c. 

6.  Parasites — e.g..  hydatids. 

r  Cystic. 

7.  New  growths — Innocent  1  o  i-j 

Malignant  J   ^%., 

8.  Deformities — e.g.,  lateral  curvature  of  spine. 

9.  Nervous  and  hysterical  affections. 
[10.  Injuries.] 


5. 


INTRODUCTORY.  1 1 

Revision  of  the  Diagnosis. 

When  the  whole  examination  of  the  case  has  been 
finished,  and  a  diagnosis,  more  or  less  complete,  has 
been  made,  it  is  often  well  to  review  once  more  all  the 
facts  that  have  been  elicited,  and  to  ask  oneself  the 
question  : 

"  Now,  can  this  be  anything  else  ?  "  or,  "  Supposing 
this  were  not  what  I  believe  it  to  be,  what  other 
diagnosis  might  possibly  be  made  ?  " 

By  exercising  this  wholesome  mental  effort,  a  mistake 
in  diagnosis  may  sometimes,  even  at  the  last  moment, 
be  avoided.  Something  else  may  occur  to  the  mind 
which,  upon  further  consideration,  may  possibly  lead  to 
an  alteration  in  the  diagnosis. 

A  too  hasty  conclusion  may  perhaps  have  been  drawn, 
and  may  require  revision. 


GHAPTEE  11. 

SURGICAL  "  HISTORY  "  AND  HOW  IT 
SHOULD  BE  TAKEN. 

Under  the  term  "  history"  is  included  all  the  informa- 
tion that  is  obtained  from  the  patient  or  his  friends  up 
to  the  time  when  the  case  comes  under  the  notice  of 
the  surgeon.  This  naturally  falls  into  three  more  or 
less  distinct  groups. 

1.  The  history  of  the  disease,  illness,  or  injury  from 

which  the  patient  is  at  present  suffering. 

2.  The  past  history,  relating  to  any  disease,  illness, 

or  injury  antecedent  to  the  commencement  of 
the  present  trouble. 

3.  The  family  history,  relating  to  diseases  whether 

of  a  similar  kind  or  not,  that  may  have  occurred 
in  other  members  of  the  patient's  family. 
Each  of   these  may  be   discussed   separately.     The 
first  is  usually  by  far  the  most  important. 

History  of  the  present  disease,  illness  or 
injury. — The  surgeon  has  to  ascertain  and  to  arrange, 
as  far  as  possible,  in  chronological  order,  all  the 
symptoms  and  physical  signs  of  which  the  patient  has 
been  the  subject  up  to  the  present  time. 


SURGICAL    "history."  1 3 

The  first  question  which  should  be  put  is,  ''What 
is  the  matter  -with  you  ?  "  or,  ''  What  is  your 

complaint  ?  "     The  next  question  should  usually  be, 
''  How  long  have  you  had  this  trouble  ?  "  (or 

these  symptoms). 

The  duration,  and  consequently  the  rate  of  progress, 
of  the  disease  being  often  a  matter  of  great  importance, 
the  surgeon  should  first  direct  attention  to  the  date  of 
the  beginning  of  the  illness,  and  ascertain  how  the 
latter  began.  He  should  endeavour  to  get  the  patient 
to  tell  him  what  were  the  symptoms  that  he  first  noticed. 
Then,  successively,  the  various  steps  in  the  progress  of 
the  disease  should  be  ascertained,  until  he  arrives  at  the 
present  condition  of  the  patient. 

The  surgeon  should  avoid  asking  leading  questions, 
except  when  absolutely  necessary.  The  patient  should 
be  induced,  as  far  as  possible,  to  tell  his  story  in  his 
own  way,  the  surgeon  merely  directing  his  questions  to 
the  elicitation  of  particular  points  which  may  seem  to 
have  an  important  bearing  upon  the  case. 

Some  patients  are,  however,  very  tiresome  in  the  way 
they  describe  their  symptoms.  They  often  lay  far  too 
much  stress  upon  unimportant  details  and  envelop  the 
really  important  facts  in  an  irrelevant  mass  of  verbal 
surplusage.  This  may  arise  from  incompetence,  from 
lack  of  intelligence  or  general  education,  from  want  of 
intelligent  observation,  and  even  sometimes  from  wilful 
misrepresentation. 

Much  care  and  attention  may  be  required  on  the  part 
of  the  surgeon  to  sift  the  grain  from  the  chaff",  to 
separate  the  really  important  points  of  the  history  from 
those  which  are  trivial  or  irrelevant. 

The  state  of  the  patient,  again,  may  be  such  as  to 


Catholic  UNiVFR^^frv 


14  SURGICAL   DIAGNOSIS. 

prevent  him  from  giving  any  intelligible  account  of  his 
symptoms.  Information  must  then  be  sought  from  the 
patient's  relations  or  friends,  or  others  who  have  had 
opportunities  of  observing  his  symptoms.  Especial 
attention  should  be  paid  to  information  communicated 
by  a  skilled  observer,  say  a  doctor  or  a  nurse.  The  in- 
formation communicated  by  unskilled  observers  should 
be  received  with  a  certain  amount  of  caution.  More 
attention  should  naturally  be  paid  to  facts  observed  by 
them  than  to  any  opinions  that  they  may  express. 

The  surgeon  should  also  be  on  his  guard  against 
accepting  too  readily  any  diagnosis  that  may  already 
have  been  made  by  other  observers,  whether  skilled  or 
not.  It  is  well  to  receive  with  a  certain  amount  of  dis- 
trust any  diagnosis  which  the  patient  himself  may  have 
made. 

It  should  be  remembered  that  the  patient,  especially 
if  he  belong  to  the  better  educated  class,  may  have  been 
reading  about  the  disease  from  which  he  supposes  him- 
self to  be  suffering,  and  may  perhaps  glibly  relate  a  long 
train  of  symptoms  which  have  little  or  no  real  existence 
save  in  his  own  imagination.  It  is  very  easy  for  an 
excitable  and  nervous  patient  to  believe  that  he  (or  she) 
really  has  the  symptoms  that  he  thinks  he  ought  to 
have. 

And  this  may  occur  without  any  idea  or  intention  of 
wilful  deception  on  the  part  of  the  patient. 

The  cautious  and  well-trained  surgeon  will  endeavour 
to  estimate  from  observation  of  the  character  of  his 
informant  the  relative  value  of  the  statements  made  by 
him.  Statements  which  appear  to  be  wholly  at  variance 
with  the  facts  observed  by  himself  should  be  received 
with  much  caution.     The  history  obtained  from  others 


SURGICAL    "history."  I  5 

is  the  more  valuable  if  it  seems  to  be  confirmed  by  what 
the  surgeon  can  observe  for  himself. 

In  endeavouring  to  assign  a  date  to  the  onset  of  a 
disease  it  must  be  remembered  that  a  patient  is  apt  to 
give  the  date  at  which  he  first  noticed  some  prominent 
symptom,  rather  than  the  date  at  which  the  disease 
really  began.  Thus  a  patient  presenting  himself  with 
an  inflamed  tumour  may  name  some  quite  recent  date 
as  that  of  the  origin  of  his  trouble.  The  patient's 
answer  may,  however,  really  refer  to  the  onset  of  the 
pain  or  the  inflammation,  rather  than  to  that  of  the 
tumour  itself. 

In  a  case  in  which  the  patient's  answer  may  seem 
to  be  open  to  misinterpretation,  it  may  be  well  to  put 
the  question  in  another  form,  and  to  say,  "How  long 
is  it  since  you  were  in  perfectly  good  health  in  all 
respects  ? "  or,  "  When  was  it  that  you  first  noticed 
anything  at  all  the  matter  with  you  ?  " 

In  the  investigation  of  the  mode  of  origin  of  a 
swelling,  or  indeed  of  any  affection,  too  much  attention 
should  not  be  paid  to  a  history  of  injury  unless  this  is 
definite  and  clear.  For  example,  a  patient  will  often 
attribute  the  origin  of  a  tumour  to  some  injury,  real  or 
imaginary,  which  may  have  had  nothing  whatever  to  do 
with  its  causation.  The  early  stages  in  the  growth  of 
a  tumour  may  entirely  escape  the  patient's  notice  until 
some,  perhaps  slight,  injury  to  the  part  draws  the 
patient's  attention  to  it,  and  a  lump  is  discovered. 
Sometimes  a  definite  injury  to  a  pre-existiug,  although 
hitherto  unnoticed,  tumour  may,  by  producing  extra- 
vasation of  blood,  inflammation,  or  other  secondary 
change,  cause  a  rapid  and  obvious  alteration  in  the 
characters  of  such  a  tumour. 


1 6  SURGICAL   DIAGNOSIS. 

In  some  cases  the  patient  has  already  been  sub- 
jected to  treatment  before  he  comes  under  observation. 
The  surgeon  will  do  well  to  bear  this  in  mind,  since 
information  upon  this  point  may  be  of  value.  A 
history  of  previous  treatment,  and  the  result  obtained 
from  it,  may  have  considerable  influence  on  the  diag- 
nosis. For  example,  in  the  case  of  a  swelling  of 
doubtful  nature,  a  history  that  previous  treatment  of  a 
similar  swelling  with  large  doses  of  iodide  of  potassium 
had  resulted  in  a  cure  might  point  to  a  diagnosis  of 
gumma.  Recent  treatment  may  also  have  masked 
the  symptoms  and  may  have  led  to  erroneous  con- 
clusions unless  the  surgeon  be  aware  of,  and  make 
allowance  for,  such  treatment.  For  example,  the  pre- 
vious administration  of  opium  may  diminish  or  conceal 
the  symptoms  of  acute  abdominal  diseases. 

Inequality  of  pupils  in  a  cerebral  case  may  lose 
much  or  all  of  its  diagnostic  value  if  a  history  of 
recent  application  of  atropin  to  the  eye  be  obtained. 
A  question  then  which  is  often  useful  is,  "Have  you 
already  had  any  treatment  for  this  complaint  ?  If  so, 
what  was  the  treatment,  and  what  was  the  effect  of  it  ?  " 

The  past  history  relates  to  any  disease,  illness, 
or  injury  antecedent  to  the  present  trouble.  This  is 
rarely  of  much  importance  in  diagnosis,  but  may, 
nevertheless,  in  some  cases  afford  an  important  clue, 
by  suggesting  a  reason  for  existing  symptoms. 

Thus  a  history  of  an  attack  of  some  specific  fever, 
such  as  enteric,  may  suggest  a  cause  for  an  otherwise 
doubtful  inflammatory  swelling,  say  of  the  tibia,  since 
it  is  well  known  that  specific  fevers  are  apt  to  leave 
behind  them  a  tendency  to  sequelae  such  as  inflam- 
matory affections  of  bone. 


CA"fHOUC    IJl 


SURGICAL    "  HISTORY."  1 7 

A  history  of  some  previous  tuberculous  affection  of  a 
joint  may  suggest  that  the  present  trouble  is  likely  also 
to  be  of  a  tuberculous  nature,  since  a  patient  who  has 
once  suffered  from  tubercle  is  not  unlikely  to  become 
affected  at  some  subsequent  period  with  some  other 
manifestation  of  the  same  disease. 

A  history  of  a  former  operation  upon  the  abdomen, 
such  as  ovariotomy,  may,  by  suggesting  intraperitoneal 
adhesions,  afford  a  clue  to  the  nature  of  an  obscure 
case  of  intestinal  obstruction. 

The  occupation  and  habits  of  life  of  the  patient 
may  also  throw  light  upon  the  nature  of  the  present 
trouble.  It  is  hardly  necessary  to  give  examples  to 
illustrate  this,  but  the  liability  of  drunkards  to  delirium 
tremens,  of  painters  to  wrist  drop^  of  woolsorters  to 
anthrax,  of  stablemen  to  glanders,  are  examples  that 
readily  occur  to  the  mind.  In  each  of  these  cases  the 
habits  of  life  or  the  occupation  might  in  a  doubtful  case 
afford  considerable  help  in  the  diagnosis  of  the  above- 
named  affections. 

A  history  of  residence  in  a  foreign  country,  or  in 
some  locality  where  a  certain  disease  is  common,  may 
be  of  importance,  and  suggest  some  disease  that  is 
unknown  or  uncommon  in  the  place  in  which  the 
patient  comes  under  observation. 

A  boy  presented  himself  with  a  paralysis  of  some  of  the 
muscles  of  one  leg,  at  first  suggesting  infantile  paralysis. 
The  fact  that  he  had  lived  for  many  years  in  the  West 
Indies  suggested  the  possibility  of  the  paralysis  being  due  to 
leprosy.  This  surmise  was  confirmed  by  the  subsequent 
appearance  of  various  characteristic  lesions  of  the  skin  and 
mucous  membranes. 

A   young  man  presented  himself  on  account  of   slight 

B 


1 8  SURGICAL   DIAGNOSIS. 

hgematuria,  which  had  been  supposed  to  be  due  to  stone. 
The  history  that  he  had  recently  spent  several  years  in  South 
Africa  suggested  a  search  for  the  ova  of  Bilharzia  haema- 
tobia,  and  the  discovery  of  numbers  of  these  in  the  urine 
made  the  diagnosis  clear. 

A  history  of  residence  in  a  malarious  district,  or  o£  a 
previous  attack  of  malaria,  may  give  a  clue  to  the 
nature  of  an  otherwise  obscure  elevation  of  temperature. 

The  family  history  is  but  rarely  of  any  real  impor- 
tance in  diagnosis.  A  few  diseases,  however,  show  a 
marked  tendency  to  be  transmitted  from  one  generation 
to  another,  and  a  history  of  such  a  disease  in  a  near 
relation  may  occasionally  throw  some  light  upon  the 
problem  of  diagnosis. 

Perhaps  the  best  examples  of  hereditary  transmission 
of  disease  are  afforded  by  haemophilia  and  colour-blind- 
ness. In  the  diagnosis  of  the  former,  family  history  is 
often  of  much  importance. 

Tubercle,  again,  is  a  disease  that  is  often  found  to 
exist  in  many  members  of  one  family,  and  may  to  a 
certain  extent  be  considered  to  be  hereditary.  At 
any  rate  a  susceptibility  to  this  disease  may  be  here- 
ditary. 

It  must  not  be  forgotten,  however,  that,  quite  apart 
from  heredity,  various  members  of  a  family  may  become 
affected  with  the  same  disease,  owing  to  some  common 
influence  to  which  they  have  all  been  exposed. 
Thus  bronchocele,  probably  truly  hereditary  to  a  very 
small  extent,  is  frequently  seen  to  affect  many  mem- 
bers of  one  family  and  even  generation  after  genera- 
tion in  the  same  family.  The  individuals,  however, 
in  these  cases,  will  usually  be  found  to  have  been 
exposed    in  early  life  to  some  common  source  of  the 


SURGICAL    "history."  1 9 

disease,  having  lived  in  a  goitrous  district  and  drunk 
goitriferous  waters. 

The  various  members  of  a  family  who  have  been 
brought  up  together,  or  in  a  similar  manner,  may 
show  a  tendency  to  develop  similar  diseases,  such  as 
rickets,  due  to  improper  feeding,  and  various  affections 
due  to  want  of  exercise,  bad  ventilation,  bad  water 
supply,  insanitary  surroundings,  &c. 

In  these  cases,  the  family  history  of  disease  is  due 
rather  to  community  of  surrounding  influences  than 
to  a  true  hereditary  tendency. 

The  less  we  know  of  the  causes  of  disease  the  more 
likely  are  we  to  attribute  to  heredity  what  is  really  due 
to  community  of  external  causation. 

Tumours,  especially  malignant  tumours,  are  by  some 
considered  to  be  markedly  hereditary,  and  it  is  often 
impossible  to  say  whether  the  existence  of  tumours  in 
two  or  more  members  of  a  family  is  to  be  attributed 
to  heredity  or  to  the  common  influence  of  some  un- 
known cause.  There  is  some  evidence  to  show  that  the 
formation  of  certain  tumours  is  connected  with  the 
locality  in  which  these  patients  have  lived. 

A  common  popular  notion  exists  that  tumours  are 
hereditary.  It  is  not  uncommon  for  a  patient,  upon 
being  told  that  he  or  she  has  a  cancer,  to  reply,  "I 
cannot  understand  how  that  can  be,  for  no  member  of 
my  family  has  ever  had  cancer." 

A  hereditary  history  of  cancer  should  have  very  little,  if 
any,  influence  upon  the  diagnosis  of  a  malignant  tumour. 

Indeed,  family  history  affords  but  little  help  in  the 
diagnosis  of  any  disease,  unless  such  history  is  very 
marked  and  clear. 


CHAPTER    III 

PHYSICAL  EXAMINATION,  AND  HOW 
TO  MAKE  IT.  METHODS  OF  EXAM- 
INATION. 

The  various  methods  that  we  employ  in  the  physical 
examination  of  a  patient  may  be  grouped  as  follows : 

I.  Examination  of  the  patient  by  the  unaided 
senses  of  sight,  touch,  hearing,  and  occasionally 
smell. 

II.  Examination  by  various  instruments,  simple 
or  complex,  which  aid  these  senses,  or  give  us  inform- 
ation upon  special  points. 

III.  Examination  of  secretions,  excretions,  and 
discharges,  and  of  the  blood  of  the  patient. 

IV.  Examination  by  means  of  anaesthetics  and 
other  drugs. 

V.  Operative  procedures. 

Each  of  these  groups  may  be  discussed  separately. 

I.  Examination  of  the  patient  by  the  un- 
aided senses  of  sight,  touch  and  hearing. 

Inspection. — This  should  be  general  as  well  as  local. 
The  surgeon  should  notice  any  peculiarity  of  manner  or 
disposition.     He  should    examine   the   patient's  face, 


PHYSICAL   EXAMINATION.  2  1 

which  may  betray  signs  of  ill  health,  or  of  intemperate 
habits,  or  give  some  other  clue  to  the  disease  from  which, 
he  is  suffering. 

The  state  of  nutrition  of  the  body  should  also  be 
noticed ;  emaciation,  obesity,  muscularity,  are  points 
to  which  attention  should  be  directed. 

The  condition  of  the  skin  and  mucous  membranes  as 
regards  pallor,  congestion,  sallowness,  jaundice,  bronz- 
ing, &c.,  should  be  noticed. 

Care  should  be  taken  to  place  the  patient  as  far  as 
possible  in  a  good  light ;  and  if  artificial  light  is  being 
used,  allowance  should  be  made  for  the  yellowness  of 
such  a  light. 

If  complaint  be  made  of  some  local  affection,  the  part 
affected  should  be  inspected  thoroughly  and  minutely, 
and  from  different  points  of  view. 

If  necessary,  many  different  parts  of  the  body  may 
have  to  be  examined. 

It  is  well  to  bear  in  mind  the  six  principal  systems  of 
the  body — digestive,  respiratory,  circulatory,  nervous, 
locomotor,  and  genito-urinary.  Attention  should  be 
paid  to  each  of  these,  and  a  more  or  less  thorough 
examination  of  each  or  all  of  them  may  be  required. 

Palpation  should  be  performed  with  as  much  gen- 
tleness as  possible,  especially  if  the  affected  part  be 
inflamed  or  tender. 

As  a  rule,  the  w^hole  hand  should  at  first  be  laid  upon 
the  affected  part.  Large  swellings  especially  should 
be  examined  in  this  way. 

The  common  method  of  examining  with  the  tips 
of  the  fingers  is  generally  not  so  useful,  unless  the 
affected  part  be  very  small,  or  not  accessible  for  exami- 
nation with  the  hand. 


2  2  SURGICAL   DIAGNOSIS. 

Percussion  is  emp)loyed 

i.  To  elicit  tenderness,  e.g.,  in  the  examination  of 
suspected  caries  of  the  spine,  by  tapping  upon  the 
vertebrae.  Percussion  of  superficial  bones,  such  as  the 
tibia  or  skull,  may  reveal  the  existence  of  local  tender- 
ness, indicating  inflammation. 

ii.  To  detect  the  presence  of  gas  or  liquid  in  a  cavity, 
e.g.,  pleura,  abdomen,  &c.,  or  of  solid  or  liquid  in  a  part 
that  should  normally  be  resonant,  e.g.,  parts  of  the 
chest  or  abdomen. 

Mensuration,  or  measuring,  is  employed  chiefly 
in  the  examination  of  the  limbs,  and  in  comparing  one 
side  of  the  body  with  the  opposite  one.* 

It  may  be  effected  by  the  eye,  by  the  hand,  or  by  the 
measuring  tape.  The  surgeon  should  accustom  himself 
to  use  all  three  methods,  and  not  to  depend  too  much 
upon  any  one  of  them. 

The  shortening  of  the  lower  limb  in  cases  of  hip 
disease  or  fracture  of  the  neck  of  the  femur,  the  increase 
of  circumferential  measurement  of  the  shoulder  in  cases 
of  dislocation,  are  examples  of  the  value  of  mensuration 
in  diagnosis. 

Auscultation  is  employed  less  by  the  surgeon  than 
by  the  physician,j-  and  its  use  is  limited  in  the  main  to 
the  examination  of  the  thorax  and  abdomen. 

It  is  also  employed,  however,  in  the  examination  of 
the  various  kinds  of  aneurism,  and  to  detect  friction 
of  roughened  or  inflamed  serous  membranes  upon  each 
other. 

*  Mensuration  of  cavities,  ducts,   sinuses,  &c..  will  be  discussed 
under  the  head  of  Instruments  (p.  26). 
f  A  good  surgeon  does  not  neglect  the  art  of  medicine. 


PHYSICAL    EXAMINATION.  23 

II.  Instruments  used  for  diagnosis. 

These  may  be  classified  as  follows  :  * 

1.  Instruments  for  aiding  inspection. 

2.  Instruments  for  aiding  palpation  and  mensuration. 

3.  Instruments  for  injecting  or  withdrawing  fluids 
(insufflators,  syringes,  catheters,  &c.). 

4.  Other  instruments  serving  special  purposes  (ther- 
mometer, electric  battery,  &c.). 

I.  Instruments  for  aiding  inspection  are  : 
(i)  Simple    magnifying    lenses   used  for  the 

minute  inspection  of  the  skin  in  some  skin  diseases,  the 

conjunctiva  and  other  superficial  parts. 

(2)  Simple  specula  (aural,  nasal,  vaginal,  rectal, 
and  urethral).  These  are  employed  in  the  examination 
of  cavities  not  readily  accessible  to  the  unaided  sight. 
Most  of  them  serve  the  double  purpose  of  reflecting 
light  into  the  cavity  and  of  retracting  or  separating  its 
margins. 

(3)  Reflectors  (with  or  without  the  addition  of 
lenses)  form  an  important  group  of  instruments  used  for 
examining  internal  cavities  (ophthalmoscope,  otoscope, 
laryngoscope,  cystoscope,  urethroscope,  oesophagoscope, 
&c.). 

The  simplest  type  of  these  is  the  laryngoscope. 

A  more  complicated  form  is  the  ophthalmoscope,  in 
which  various  lens  are  introduced.  Still  more  com- 
plicated forms  are  those  in  which  an  electric  light  is 
carried  on  the  instrument  itself  into  the  interior  of  the 
cavity  that  is  to  be  examined  (cystoscope,  for  example). 

*  The  numerous  instruments  that  are  used  in  the  chemical,  micro- 
scopical, bacteriological,  or  other  examinations  of  secretions,  dis- 
charges, blood,  &c.,  and  are  not  applied  directly  to  the  patient,  need 
not  be  described. 


24  SURGICAL    DIAGNOSIS. 

In  certain  cases  use  is  made  of  transmitted  light. 
Tlie  lio'ht  thus  used  mav  be — 

(a)  Ordinary  daylight. 

(b)  Artificial  light  from  candle,  lamp,  &c. 

(c)  Light  of  Rontgen  rays  (X-rays). 

(a)  Ordinary  daylight  is  used  mainly  in  the  detection 
of  clear  fluid  contained  in  a  cavity  near  the  surface  and 
having  a  thin  wall  ;  a  hydrocele  of  the  tunica  vaginalis 
is  the  example  that  at  once  suggests  itself. 

(b)  Examination  by  artificial  light  should  be  made  in 
a  darkened  spot,  and  a  hand  placed  vertically  upon  the 
part  is  usually  sufficient  to  cut  off  the  direct  rays  of 
light  which  otherwise  might  interfere  with  the  inspec- 
tion of  transmitted  light. 

If  a  more  accurate  examination  is  required,  it  must 
be  made  in  absolute  darkness,  and  the  transmitted  light 
should  be  directed  to  the  eye  of  the  observer  through  a 
tube  placed  upon  the  part.  An  ordinary  stethoscope  or 
a  roll  of  paper  are  the  tubes  usually  employed  for  this 
purpose. 

Sometimes  an  artificial  (electric)  light  is  introduced 
into  the  interior  of  the  body  (stomach,  mouth),  and  the 
transmitted  light  is  made  to  reveal  diseases  situated 
between  the  light  and  the  eye  of  the  observer. 

These  examinations  must,  of  course^  be  conducted  in 
an  absolutely  dark  room.  This  method  is  of  great  value 
in  the  examination  of  the  sinuses  about  the  face  (antrum, 
frontal  sinus).* 

(c)  Examination  by  X-rays. — Much  use  may  be  made 
of  the  important  discovery  of  Prof..  Rontgen  that  most 
parts  of  the  body  that  are  nearly  or  wholly  opaque 
to    ordinary    light     are    nevertheless    translucent    as 

*  See  chap.  iv. 


PHYSICAL   EXAMINATION.  25 

regards  these  remarkable  rays,  now  usually  known  as 
X-rays. 

Other  parts  of  the  body,  however,  and  notably  the 
bones,  are  opaque  both  to  ordinary  light  and  to  the 
X-rays. 

The  rays  in  passing  through  the  body  cast  shadows 
of  the  opaque  parts  through  which  they  themselves  can- 
not pass.  These  shadows  may  be  rendered  visible  upon 
a  fluorescent  screen^  or  they  may  be  directed  upon  a 
photographic  plate,  which  is  subsequently  developed 
into  a  negative  in  the  ordinary  manner. 

It  is  important  to  remember  that  the  images  thus 
obtained  are  not  true  pictorial  representations,  but  are 
merely  shadows. 

Hence,  if  the  opaque  object  is  small,  and  at  some 
distance  from  the  plate,  little  or  no  distinct  shadow  may 
be  cast.  Small  calculi  in  the  kidney,  for  example, 
may  give  no  appreciable  shadow  when  looked  for  in 
this  way. 

Eontgen  rays  are  of  use  in  surgical  diagnosis  chiefly 
in  connection  with  injuries  and  diseases  of  bones  and 
joints,  and  in  the  detection  of  foreign  bodies. 

Considerable  skill,  however,  is  often  necessary  in  the 
interpretation  of  the  appearances  seen  in  these  photo- 
graphs, and  mistakes  are  not  uncommon. 

Large  collections  of  blood,  such  as  those  in  an 
aneurism,  are  tolerably  opaque  to  the  rays  and  may 
thus  be  rendered  apparent. 

Attempts  have  been  made  to  render  the  shape  and 
position  of  certain  internal  organs  visible  by  putting 
metallic  substances  into  them  and  then  exposing  to  the 
X-rays. 

Thus  attempts  have  been  made  to  render  the  shape 


2  6  SURGICAL   DIAGNOSIS. 

and  situation  of  the  stomacli  visible  by  placing  within 
it  an  innocuous  metallic  salt,  such  as  subnitrate  of 
bismuth,  which  is  opaque  to  the  X-rays.  But  the 
information  thus  obtained  is  not  very  precise  or 
reliable. 

The  exact  situation  of  the  opaqae  object  (say,  a 
foreign  body  in  a  limb)  may  be  ascertained  by 
examining  in  two  directions,  at  right  angles  to  each 
other,  or  by  the  employment  of  Mackenzie-Davidson's 
ingenious  apparatus  by  which  a  stereoscopic  picture 
is  obtained. 

2.  Instruments  for  aiding  palpation  and 
mensuration. — For  measuring  the  surface  of  the 
body  which  is  readily  accessible,  the  simple  measuring 
tape  is  employed.  If  a  very  exact  measurement  of  the 
shape  of  any  part  of  the  body  be  required,  a  cyrtometer 
is  sometimes  used.  This  consists  simply  of  a  flexible, 
non-elastic,  metallic  band,  usually  an  alloy  of  lead, 
which  can  be  moulded  to  the  part,  and  which  is  suffi- 
ciently rigid  to  retain  its  shape  after  removal.  Exact 
comparative  measurements  of  the  shape  of  the  two 
sides  of  the  thorax,  abdomen,  &c.,  are  thus  obtained. 
The  degree  of  deformity  of  the  spine  in  a  case  of 
caries  may  thus  be  recorded  for  comparison  with 
similar  measurements  taken  at  some  other  stage  of  the 
disease.  Casts  in  plaster  of  Paris,  gutta  percha,  and 
other  materials,  as  well  as  photographs,  may  be  used  for 
the  similar  pur[3ose  of  making  exact  records. 

The  instruments  that  are  chiefly  employed  in  aiding 
palpation  and  mensuration  are,  hov/ever,  those  that  are 
used  in  the  examination  of  internal  cavities  which  from 
their  size  or  distance  from  the  surface  do  not  readily 
permit  of  direct  examination  with  the  finger. 


PHYSICAL    EXAMINATION.  27 

Such  instruments  are  probes,  sounds,  and  bougies,  all 
of  which  may  be  regarded  in  the  light  of  a  long  and 
narrow  finger,  introduced  into  a  sinus,  duct  or  other 
cavity  to  determine  its  direction,  size,  shape,  &c.  The 
use  of  metal  facilitates  the  detection  of  hard  substances, 
such  as  dead  bone  at  the  bottom  of  a  sinus  or  a  calculus 
in  the  bladder  or  salivary  duct. 

The  internal  measurement  of  such  cavities  as  the 
uterus  or  bladder  is  obtained  by  passing  an  instrument 
of  this  class.  Occasionally  a  more  complicated  instru- 
ment may  be  used  for  an  internal  measurement,  as  when 
a  lithotrite  is  introduced  into  the  bladder  to  measure 
the  size  of  a  calculus. 

3.  Instruments  for  injecting  or  withdravr- 
ing  fluids. — Air  may  be  injected  into  the  middle  ear 
by  means  of  a  Eustachian  catheter  and  Politzer's  bag, 
in  order  to  diagnose  various  diseases  of  the  membrana 
tympani  and  middle  ear. 

The  stomach  and  large  intestine  are  occasionally 
filled  with  air  by  means  of  a  tube  and  insufflator,  in 
order  to  determine  their  exact  situation  and  relations 
to  surrounding  parts.  Water  may  be  injected  into  the 
bladder  or  rectum  to  determine  the  capacity  of  these 
cavities. 

Catheters  and  stomach  tubes  are  used  for  withdraw- 
ing fluids  from  the  bladder  and  stomach. 

4.  Other  instruments  serving  special  pur- 
poses.— Under  this  heading  may  be  mentioned  the 
thermometer,  the  stethoscope,  the  tuning-fork,  and  the 
sphymograph,  the  uses  of  which  are  obvious.  The 
electric  battery  is,  of  course,  of  much  use  in  the  exami- 
nation of  the  nervous  and  muscular  system  (as  well  as 
in  the  production  of  artificial  light)  ;  two  forms  of  current 


28  SURGICAL   DIAGNOSIS. 

are  employed,  the   constant  or  galvanic  and  the  inter- 
rupted or  Faradic. 

Before  leaving  the  subject  of  instrumental  exam- 
ination it  may  be  well  to  add  that  much  harm 
m.ay  be  done  to  the  patient  by  the  injudicious, 
careless,  or  improper  use  of  instruments,  especially 
by  those  which  are  introduced  into  the  interior  of  the 
body. 

Harm  may  be  inflicted  by 
(i)  Mechanical  injury, 
(ii)  Introduction  of  septic  matter. 

(i)  The  perforation  of  the  wall  of  a  hollow  viscus  may 
easily  be  effected  by  the  careless  introduction  of  a  rigid 
and  pointed  instrument.  Perforation  of  the  wall  of 
the  oesophagus,  urethra,  rectum  or  uterus  by  bougie  or 
catheter  are  familiar  examples.  The  bladder  and  large 
intestine  may  be  ruptured  from  forcible  over  disten- 
sion. 

Laceration  of  the  wall  of  the  cavity  may  lead  to 
haemorrhage  and  inflammation,  which  in  turn  may  set 
up  very  serious  trouble. 

All  these  accidents  are  naturally  more  likely  to 
occur  when  the  wall  of  the  cavity  has  been  softened 
and  weakened  by  inflammation,  ulceration,  new  growth 
or  other  disease.  The  healthy  wall  of  a  mucous  cavity 
can  scarcely  be  perforated  or  ruptured  except  by  gross 
carelessness  and  the  use  of  a  quite  unjustifiable  degree 
of  force. 

Burning  of  the  mucous  membrane  is  not  a  very 
uncommon  accident  when  an  electric  light  is  intro- 
duced into  a  mucous  cavity  and  kept  there  too  long 
{e.g.,  in  cystoscopy).* 

*  I  have  known  a  case  in  which  a  bad  burn  of  the  soft  palate  was 


PHYSICAL   EXAMINATION.  29 

The  prolonged  application  of  X-rays,  especially  if  the 
patient  be  under  the  influence  of  an  anaesthetic,  may 
produce  a  severe  burn. 

(ii)  The  introduction  of  septic  matter  frequently  leads 
to  the  most  dire  consequences,  in  connection  especially 
with  the  urinary  organs.  The  harm  that  may  be  done 
by  the  introduction  of  a  dirty  catheter  into  the  bladder 
is  so  well  known  that  it  need  only  be  mentioned.  The 
harm  thus  done  is  largely,  but  not  wholly,  avoidable, 
since  a  perfectly  aseptic  catheter  may  be  rendered 
septic  by  its  passage  through  the  urethra.  Not  only 
should  a  catheter  be  rendered  aseptic  before  introduc- 
tion, but  the  urethra  itself  should  as  far  as  possible  be 
cleansed  (a)  by  making  the  patient  pass  water  beforeithe 
instrument  is  introduced,  and  (h)  by  washing  the  orifice 
of  the  urethra  with  some  antiseptic  lotion.* 

III.  Examination  of  secretions,  excretions, 
and  discharges  or  of  the  blood. 

Secretions  and  excretions. 

The  chief  points  to  which  attention  should  be  paid  are 
the  following : 

Are  they  increased  or  diminished  in  amount  ?  (e.g., 
diminution  of  salivary  secretion  in  obstruction  of 
salivary  duct,  of  urine  in  uraemia ;  increase  of  urine  in 
diabetes). 

Is  there  increase  or  diminution  of  any  one  or  more  of 
the  normal  constituents  ?  {e.g.,  decrease  of  urea  in  many 
kidney  affections,  of  free  hydrochloric  acid   in  gastric 

caused  by  the  introduction  of  an  over-heated  laryngeal  mirror. 
Cases  of  every  one  of  the  above-mentioned  accidents  have  come 
under  my  own  personal  notice,  chiefly  during  the  periods  in  which 
I  held  the  posts  of  house  surgeon,  house  physician,  and  surgical 
registrar. 

*  And  yet  how  often  do  we  see  these  simple  precautions  neglected! 


30  SURGICAL    DIAGNOSIS. 

juice,,  in  caucer  of  the  stomach,  increase  of  mucus  in 
the  urine  in  cystitis.) 

Is  any  abnormal  substance  present  ?  {e.g.,  sugar,  albu- 
men, blood,  or  pus,  in  the  urine  of  diabetes,  nephritis, 
cancer  of  the  bladder,  or  tuberculous  pyelitis  ;  blood, 
sarcinse,  or  lactic  acid  in  the  vomited  contents  of  the 
stomach,  gallstones  or  undigested  fat  in  the  faeces,  bits 
of  villous  growth,  ova  of  Bilharzia  hsematobia,  sand  or 
gravel  in  the  urine.) 

The  examination  of  secretions  and  excretions  may  be 
made  with  the  naked  eye,  or  may  require  more  elaborate 
investigation  in  the  laboratory  by  the  aid  of  the  micro- 
scope, chemistry,  bacteriology,  or  even  experimental 
injection  into  animals,  as  in  the  detection  of  tubercle, 
anthrax,  &c. 

Discharges  from  ulcers,  sinuses  on  mucous  or  cuta- 
neous surfaces,  may  require  minute  examination  with 
reference  to  quantity,  quality,  presence  of  pus,  blood, 
bacteria,  as  in  tuberculosis  ;  fungi,  as  in  actinomycosis  ; 
epithelial  or  other  cells,  as  in  epithelioma,  &c.  For 
many  of  the  preceding  examinations  the  most  elabo- 
rate appliances  of  the  laboratory,  too  numerous  for 
mention,  may  be  required. 


Examination  of  the  Blood. 

This  is  of  more  importance  to  the  physician  who 
has  to  deal  with  such  diseases  as  chlorosis,  leuksemia, 
malaria,  and  typhoid  fever,  than  it  is  to  the  surgeon. 
The  latter  finds  blood  examination  of  value  chiefly  in 
the  determination  of  deep-seated  suppuration. 

Examination  of  the  blood  from  the  surgical  point  of 


PHYSICAL    EXAMINATION.  3I 

view  may  be  made  to  ascertain  (i)  the  number  of 
corpuscles  (red  and  white)  that  are  present  in  it ;  (ii) 
the  existence  and  relative  proportion  of  the  different 
kinds  of  white  corpuscles  ;  (iii)  the  amount  of  haemo- 
globin ;  (iv)  the  presence  of  micro-organisms. 

(i)  In  endeavouring  to  estimate  the  number  of 
corpuscles  in  the  blood,  the  method  is  that  of  remov- 
ing a  drop  of  blood,  diluting  it,  and  then  counting  the 
actual  number  of  corpuscles  seen  in  a  known  volume  of 
blood  under  the  microscope.  In  order  to  avoid  errors, 
much  care  has  to  be  taken  to  make  allowance  for  physio- 
logical alterations  in  the  number  of  corpuscles  which 
occur  within  the  limits  of  health.  Care  must  also  be 
taken  to  withdraw  and  mount  the  specimen  of  blood 
sufficiently  quickly,  since  the  relative  proportions  of 
plasma  and  cells  alter  very  rapidly  by  precipitation  of 
the  latter  as  soon  as  the  blood  is  removed  from  the 
body. 

For  practical  purposes  it  may  be  assumed  that,  under 
ordinary  circumstances,  the  blood  of  a  healthy  adult 
should  contain  5,000,000  red  corpuscles  and  8000  white 
corpuscles  (leucocytes)  per  cubic  millimetre.  Age,  in- 
dividual peculiarities,  the  time  of  day  at  which  the 
examination  is  made,  and  especially  digestion,  affect 
seriously  the  value  of  these  figures.  The  examination 
should  be  made  some  four  hours  after  a  meal,  and 
successive  examinations  should  be  made  at  the  same 
hour  each  day. 

Leucocytosis,  or  increase  in  the  number  of  white 
corpuscles  as  a  physiological  process,  is  most  marked 
in  connection  with  digestion.  In  newly  born  infants 
and  in  women  shortly  after  childbirth  a  high  degree  of 
physiological  leucocytosis  is  found  which  may  amount 


32  SURGICAL   DIAGNOSIS. 

to  more  than  double  the  normal.  As  a  pathological 
process,  the  interest  of  leucocytosis  to  the  surgeon 
lies  chiefly  in  connection  with  inflammatory  processes. 
Leucocytes  play  an  important  part  in  the  destruction 
of  bacteria  which  have  obtained  entrance  into  the 
circulation.  "  Leucocytosis  represents  Nature's  attempt 
to  rid  the  blood  and  the  system,  by  means  of  leuco- 
cytes and  their  products,  of  the  bacterial  and  toxic 
causes  of  disease."* 

Leucocytosis  does  not  necessarily  occur  in  all  cases  of 
abscess.  If  the  pus  be  shut  off  from  the  general  circu- 
lation by  a  well-marked  abscess  wall  there  may  be  no 
leucocytosis.  The  degree  of  leucocytosis  is  no  guide  to 
the  amount  of  pus  that  is  present.  It  indicates  rather 
the  amount  of  septic  absorption  that  is  taking  place. 
But  it  must  also  be  remembered  that  in  some  of  the 
most  severe  and  rapidly  fatal  cases  of  sepsis,  as  in  very 
severe  forms  of  fulminating  appendicitis,  there  may  be 
no  leucocytosis. 

In  the  diagnosis  between  internal  haemorrhage  and 
deep-seated  suppuration  in  the  abdomen  or  pelvis 
(pyo-salpinx  and  haamatocele,  for  example),  a  blood 
count  may  help.  Diminution  in  red  corpuscles  and  in 
haemoglobin  would  suggest  haemorrhage  ;  leucocytosis 
would  be  in  favour  of  suppuration. 

(ii)  The  various  kinds  of  leucocytes  that  may  be 
found  in  normal  blood  and  under  various  pathological 
conditions  are  divided  into  groups  according  to  their 
behaviour  when  stained  with  various  aniline  dyes. 
Some  of  the  dyes,  such  as  hgematoxylon  and  methylene 

*  Ewing,  "Clinical  Pathology  of  the  Blood,"  1901,  to  which 
reference  may  be  made  for  further  details  upon  the  whole  of  this 
subject. 


PHYSICAL   EXAMINATION.  33 

blue,  are  basic  ;  others,  such  as  eosin  and  fuchsine,  are 
acid  ;  while  a  third  class,  composed  of  compounds  of 
certain  basic  and  acid  dyes,  of  which  Ehrlich's  triacid 
stain  is  an  example,  are  known  as  neutral  dyes. 

According  to  Ewing,*  in  stained  specimens  of  normal 
blood  the  following  four  varieties  of  leucocytes  may 
be  found : 

1.  Lymphocytes,  22-25  P©^  cent. 

2.  Large  mononuclear  leucocytes,  2-4  per  cent, 
(basophile). 

3.  Polynuclear  leucocytes,  70-72  per  cent,  (neu- 
trophile). 

4.  Eosinophile  leucocytes,  2-4  per  cent,  (eosinophile). 
Besides  these  leucocytes,  which  alone  occur  in  normal 

blood,  there  are  found  in  pathological  blood : 

1.  Myelocytes  of  various  kinds,  which  are  large 
mononuclear  cells,  some  with  neutrophil e  and  others 
with  eosinophile  properties. 

2.  Mast  cells,  whose  characteristic  feature  is  the  pre- 
sence of  large  and  small  strongly  basophile  granules. 

In  the  investigation  of  white  corpuscles  we  must 
therefore  take  into  account  not  merely  the  actual 
number  of  corpuscles  present,  but  the  relative  number 
of  the  various  kinds.  For  this  purpose  stained  blood 
films  are  examined. 

In  distinguishing  between  lymphadenoma  and 
leukaemia,  for  example,  a  blood  examination  is  of 
great  value.  In  the  former  disease  it  is  the  poly- 
nuclear cells  that  are  in  excess  ;  in  the  latter  it  is 
the  myelocytes  (large  mononuclear  cells  with  granular 
eosinophile  protoplasm)  that  afford  evidence  of  the 
disease. 

*  Loc.  cit. 


34  SURGICAL   DIAGNOSIS. 

In  certain  cases  of  disease  due  to  parasitic  intestinal 
worms  {e.g.,  trichinosis)  there  is  an  enormous  increase  in 
the  eosinophile  cells,  which  in  normal  blood  are  found  to 
constitute  only  from  2  to  4  per  cent,  of  the  leucocytes. 

(iii)  Estimation  of  the  haemoglobin  in  blood  is  of 
much  less  importance  than  estimation  of  the  number 
and  nature  of  the  corpuscles.  Various  forms  of 
haemoglobinometer  may  be  employed.  The  essential 
principle  is  that  of  comparison  of  the  colour  of  a  solu- 
tion of  the  blood  of  a  known  degree  of  dilution  with  a 
normal  standard  colour.  Patients  whose  haemoglobin 
has  fallen  very  low  (from  haemorrhage  or  other  cause) 
may  be  unfit  to  bear  severe  operations  necessitating 
further  loss  of  blood.  Mikulicz  has  laid  down  a  rule 
never  to  operate  on  a  patient  whose  hsemoglobin  is 
under  30  per  cent.* 

(iv)  The  detection  of  micro-organisms  in  the 
blood  is  of  less  importance  to  the  surgeon  than  their 
detection  in  the  tissues  and  in  the  secretions. 

Even  in  severe  forms  of  pyaemia  it  may  be  impossible 
to  find  micro-organisms  in  the  circulating  blood.  The 
discovery  of  the  streptococcus  or  of  the  staphylococcus 
pyogenes  aureus  in  the  circulating  blood  of  a  pyasmic 
patient  is  a  sign  of  very  grave  import. 

The  detection  in  the  blood  of  the. micro-organisms  of 
such  diseases  as  malaria,  filariasis  and  sleeping  sickness 
concerns  the  physician  rather  than  the  surgeon. 

IV.  Use  of  anaesthetics  and  other  drugs. 

General  anaesthesia  (by  chloroform,  ether,  or 
nitrous  oxide  gas)  is  employed  for  purposes  of 
diagnosis,  principally  with  one  or  other  of  two  objects. 

*  Cabot  in  Warren  and  Gould's  "  Text-book  of  Surgery,"  1901. 


PHYSICAL   EXAMINATION.  35 

(i)  To  produce  muscular  relaxation,  in  order  that  pal- 
pation may  be  more  easily  effected,  as  for  example  in 
the  examination  of  an  abdominal  tumour  or  of  an 
obscure  fracture  about  the  hip. 

(ii)  To  avoid  causing  pain  or  distress  to  the  patient 
in  making  painful  or  disagreeable  examinations.  In 
the  case  of  young  children  the  avoidance  of  fright  is 
often  desirable,  especially  if  the  examination  is  likely 
to  be  a  prolonged  one. 

In  making  an  examination  under  an  anaesthetic,  it 
should  be  remembered  that  it  is  quite  possible  to  do 
the  patient  grievous  bodily  harm,  if  the  examination 
be  carelessly  or  injudiciously  performed.  A  joint  that 
is  the  seat  of  an  acute  or  subacute  inflammation  may 
be  made  very  much  worse  by  a  prolonged  examination 
under  an  anaesthetic.  An  intra-abdominal  abscess, 
more  or  less  protected  by  the  rigidity  of  the  abdominal 
muscles  while  the  patient  is  conscious,  may  easily  be 
ruptured  by  careless  manipulation  during  ansesthesia. 
A  surgeon  is  sometimes  a  little  apt  to  forget  that  he 
may  by  his  examination  be  doing  much  harm  to  his 
patient,  even  although  the  latter  is  unconscious  of  any 
pain. 

Local  anaesthesia  (by  cocaine,  or  eucaine),  for 
the  purposes  of  diagnosis,  is  employed  chiefly  to  allay 
pain  or  spasm  during  the  instrumental  examination  of 
mucous  cavities,  such  as  the  larynx  or  rectum. 

The  local  anaesthesia  ^^I'cx^uced  by  injecting  these 
drugs  into  the  spinal  cord,  although  occasionally  used 
for  the  purposes  of  treatment,  is  not  used  for  merely 
diagnostic  purposes. 

Other  drugs  are  sometimes  used  for  diagnostic 
purposes. 


36  SURGICAL   DIAGNOSIS. 

Some,  such  as  atropin,  applied  locally  to  the  eye, 
render  examinafcion  more  easy.  Atropin  also,  by 
causing  irregularity  of  the  dilated  pupil,  may  render 
evident  the  existence  of  adhesions,  and  thus  indicate 
previous  iritis. 

Others,  by  producing  or  not  producing  certain  effects, 
may  aid  in  diagnosis ;  thus  an  injection  of  pilocarpin 
by  causing  copious  unilateral  sweating  of  the  head  and 
face  may  be  of  use  in  demonstrating  paralysis  of  the 
cervical  sympathetic. 

The  injection  of  tuberculin  may  be  useful  in  certain 
cases,  the  existence  of  an  obscure  tuberculous  lesion 
being  demonstrated  by  the  reaction  which  takes  place. 
Conversely,  the  absence  of  any  reaction  after  the  injec- 
tion of  the  drug  will  show  the  absence  of  tuberculosis. 
Much  care  must  be  exercised,  however,  in  the  use  of  this 
drug.  A  pure  and  reliable  sample  must  be  employed, 
and  it  should  be  borne  in  mind  that  the  employment  of 
this  method  of  diagnosis  is  not  free  from  danger. 

A  purgative  or  enema  by  emptying  the  intestines 
may  obviously  be  of  great  use  in  the  examination  of 
the  abdomen  or  pelvis.  A  suspected  tumour  in  these 
regions  may,  by  such  simple  means,  be  proved  to  be 
nothing  but  a  mass  of  impacted  faeces. 

The  effect  of  the  administration  of  such  drugs  as 
iodide  of  potassium,  salicylate  of  soda,  mercury, 
quinine,  and  very  many  others  may  afford  important 
information  with  regard  to  diagnosis. 

Conversely,  drugs  may  hinder  diagnosis,  unless  due 
allowance  be  made  for  their  having  been  administered. 
The  previous  administration  of  opium  to  a  case  of 
acute  abdominal  disease  may  materially  mask  the 
symptoms.     Morphia,    chloral,    and  other  drugs   may" 


# 


PHYSICAL    EXAMINATION.  37 

cause  temporary  glycosuria.     Many  other  similar  ex- 
amples might  be  cited. 
V.  Operative  procedures. 

Operative  proceedings  are  often  necessary  before  a 
diagnosis  can  be  made  with  certainty. 

These  procedures  fall  into  the  following  groups : 

(i)  Puncture  with  grooved  needle,  trocar  and  canula, 
or  aspirator.  This  is  done  to  see  whether  fluid  is 
present  in  the  part  and  if  so  to  withdraw  it  for  further 
examination  (cysts,  abscesses,  hj^datids,  &c.). 

In  making  such  a  puncture,  strict  antiseptic  pre- 
cautions should  be  adopted,  lest  the  introduction  of 
septic  matter  should  introduce  a  needless  and  perhaps 
serious  complication.  The  surgeon  must  also  consider 
carefully  the  anatomy  of  the  parts  which  he  is  about 
to  transfix,  and  avoid  wounding  a  large  vein,  the 
intestine,  the  peritoneum,  or  other  important  structure. 
Indeed,  the  tapping  of  any  localised  fluid  swelling 
through  the  non-adherent  peritoneum  is  not  free  from 
grave  risk  and  should  rarely  if  ever  be  performed. 

Further,  the  tapping  of  a  fluid  swelling  may,  by 
allowing  the  fluid  to  escape  externally  or  into  circum- 
jacent tissues,  lead  to  trouble.  The  tapping  of  a 
circumscribed  septic  abscess  may  lead  to  a  dangerous 
septic  cellulitis. 

The  puncture  of  a  malignant  tumour  covered  by 
healthy  skin,  peritoneum  or  other  resisting  structure  may, 
by  allowing  the  growth  to  extend  along  the  line  of 
puncture,  cause  serious  fungation  and  dissemination. 
Malignant  tumours  of  the  thyroid  gland,  for  example, 
if  left  to  themselves  rarely  come  through  the  skin.  It 
is  not  uncommon,  however,  to  see  external  fungation 
of  the  growth  at  the  site   of  an  injudicious  tapping. 


38  SURGICAL    DIAGNOSIS. 

and  the  same  may  be  said  of  many  other  parts  of  the 
body. 

(ii)  Removal  (with  scissors  or  knife)  of  a  small  solid 
portion  of  superficial  ulcer,  growth  or  other  diseased 
part  for  microscopical  or  bacteriological  examination. 

The  removal  of  a  bit  of  a  suspected  epithelioma  of 
the  tongue  for  microscopical  examination  is  a  familiar 
example. 

Such  trivial  operations  are  usually  performed  with 
the  help  of  cocaine  or  some  other  local  anaesthetic. 

(iii)  Incision  of  swellings  or  of  cavities  {e.g.,  abdomen) 
for  the  purposes  of  examination  by  the  eye,  the  finger 
or  the  hand,  or  by  some  instrument. 

Direct  incision  may  be  the  only  means  of  distin- 
guishing between  a  malignant  tumour  and  a  swelling 
of  chronic  inflammatory  nature. 

Abdominal  section  frequently  affords  the  only  means 
of  clearing  up  a  doubtful  diagnosis  of  an  obscure  dis- 
ease of  the  abdomen,  such  as  early  carcinoma  of  the 
stomach,  disease  of  the  pancreas,  &c. 

It  may  be  laid  down  as  a  general  rule  that  the  larger 
operations  of  this  class  are  not  to  be  performed  unless 
some  important  point  as  regards  prognosis  or  treat- 
ment depends  upon  them.  To  cut  into  a  malignant 
tumour  and  to  do  nothing  more  generally  leaves  the 
patient  worse  than  he  -was  before  the  operation.  If, 
however,  there  is  any  reasonable  prospect  that  the 
exploratory  ojDeration  will  pave  the  way  for  further 
curative  or  palliative  treatment,  it  should  be  under- 
taken. Similarly,  an  exploratory  abdominal  section 
should  not  be  performed  merely  for  the  purpose  of 
diagnosis  unless  there  is  some  reasonable  prospect  of 
doing  good  to  the  patient  thereby. 


PHYSICAL    EXAMINATION.  39 

In  these  days  one  bears  a  good  deal  about  the 
complete  safety  of  exploratory  abdominal  sections. 
Although  an  abdominal  section  performed  upon  a 
patient  whose  general  health  is  good  may  be,  and 
usually  is,  almost  wholly  devoid  of  danger,  yet  such  is 
by  no  means  the  case  if  the  patient  is  already  very  ill 
as  the  result  of  severe  injury  or  advanced  disease.  In 
these  cases  a  useless  abdominal  section  may  very  easily 
shorten  the  patient's  life. 

Even  the  simplest  abdominal  section  is  not  wholly 
free  from  the  risk  of  causing  peritoneal  adhesions 
which  may  at  some  future  period  lead  to  fatal  intestinal 
obstruction. 

Before  doing  any  large  exploratory  operation,  it  is 
well  to  ask  oneself  the  question,  "  What  good  to  the 
patient  can  be  expected  to  follow  this  operation  ?  Is 
there  any  reasonable  probability  or  even  possibility 
that,  under  favourable  circumstances,  the  subsequent 
treatment  of  the  case  will  be  modified  by  what  is  found 
at  this  operation  ?  " 

Exploratory  operation,  merely  to  confirm  or  to  make 
a  diagnosis  in  a  case  in  which  no  question  of  treatment 
arises  is  not  justifiable,  and  is  to  be  regarded  merely 
as  meddlesome  curiosity  on  the  part  of  the  surgeon. 

Occasionally  a  simple  exploratory  operation  may  be 
undertaken  to  settle  the  question  of  prognosis,  even 
when  treatment  is  wholly  out  of  the  question.  But 
this  should  be  done  very  rarely,  and  never  except  at 
the  express  wish  of  the  patient  and  after  all  the  facts 
of  the  case  have  been  clearly  laid  before  him. 


PART   II. 

DISEASES 

CHAPTER    lY. 

DISEASES  OF  THE  NOSE,  NASO- 
PHARYNX  AND  ACCESSORY   SINUSES. 

The  examination  of  a  case  of  disease  of  the  nose  com- 
prises tbe  examination  of  tlie  external  portion  of  that 
organ  and  of  the  interior.  The  latter  is  effected  mainly 
with  the  help  of  reflected  light,  and  with  a  probe  or 
other  instrument  introduced  into  the  cavity.  Diseases 
of  the  posterior  portion  of  the  nasal  cavity  and  of  the 
nasopharynx  are  investigated  by  means  of  the  finger 
introduced  behind  the  soft  palate,  or  by  posterior  rhino- 
scopy. In  some  few  cases  it  is  necessary  to  explore  the 
nasal  cavity  by  laying  it  open  from  the  outside,  or  by 
splitting  the  soft  palate,  before  a  complete  and  satis- 
factory diagnosis  can  be  made.  It  is  well  also  in  the 
investigation  of  a  case  of  supposed  disease  of  the  nose 
to  pay  especial  attention  to  the  condition  of  neighbour- 
ing parts,  such  as  the  antrum,  the  frontal  sinus,  the  ear, 
and  the  throat,  since  diseases  of  these  parts  are  fre- 
quently associated  with  disease  of  the  nose. 

Diseases  of  the  external  portion  of  the  nose  require 


DISEASES    OF    THE    NOSE.  4 1 

but  brief  mention.  Affections  of  the  skin  of  this  part 
do  not  differ  essentially  from  those  of  other  parts  of  the 
face.  Certain  superficial  affections  are  particularly- 
common  in  this  part,  notably  tubercle  (lupus)  in  young 
and  rodent  carcinoma  in  middle-aged  and  elderly  sub- 
jects. The  latter  in  its  early  stages  is  likely  to  be  mis- 
taken for  a  simple  wart ;  the  diagnosis  is  made  chiefly 
by  the  tendency  to  slow  and  steady  growth.  In  the  later 
stages,  when  ulceration  has  occurred,  the  distinct  slightly 
raised  hard  edge  serves  to  distinguish  it  from  all  inno- 
cent forms  of  ulceration,  while  its  slow  growth  and  the 
absence  of  any  considerable  mass  of  new  tissue  at  the 
base  of  the  ulcer,  together  with  the  absence  of  glandular 
implication,  are  usually  sufficient  to  distinguish  it  from 
epithelioma  and  other  forms  of  malignant  ulcer.  The 
diagnosis  of  lupus  of  the  nose  is  frequently  facilitated 
by  the  presence  of  characteristic  patches  upon  other 
parts  of  the  face.  The  tendency  to  spread  slowly,  and 
gradually  to  destroy  the  soft  parts  of  the  nose,  and  the 
presence  of  non-ulcerated  tubercles  in  immediate 
proximity  to  the  ulcer,  help  in  the  diagnosis. 

Destruction  of  the  bones  and  cartilages  of  the  nose  is 
frequently  caused  by  syphilis,  the  signs  of  which  can 
almost  always  be  seen  also  in  neighbouring  parts  of  the 
throat  and  mouth. 

Destruction  of  the  septum  of  the  nose  causes  a 
flattening  of  the  bridge,  which  is  very  suggestive  of 
syphilis.  The  most  marked  flattening  is  seen  in  those 
cases  in  which  the  acute  disease  has  occurred  in  child- 
hood while  the  bones  were  still  soft. 

An  extreme  case  of  atrophic  rhinitis  may  also  present 
marked  flattening  of  the  bridge  of  the  nose. 

Marked   widening  of  the    external   nose   generally 


42  SURGICAL   DIAGNOSIS. 

indicates  the  existence  of  a  tumour,  growing  slowly 
within  the  nasal  cavity  and  expanding  it.  Multiple 
simple  polypi  of  long  duration  occasionally  produce  this 
deformity.  The  firmer  fibrous  growths  that  spring  from 
the  roof  of  the  pharynx  and  nasopharynx  are  still  more 
likely  to  cause  it.  Malignant  tumours  generally  cause 
this  widening  only  in  their  later  stages,  when  diagnosis 
no  longer  presents  any  difficulty.  It  is  obvious  that 
tumours  of  any  kind  situated  at  the  anterior  part  of  the 
nose  are  more  likely  to  cause  deformity  of  the  exterior 
than  are  those  that  have  their  origin  far  back  in  the 
neighbourhood  of  the  pharynx. 

Disease  of  the  interior  of  the  nose  generally  causes 
one  or  other,  or  all  of  the  following  three  symptoms : 
I.  Obstruction ;  II.  Discharge ;  III.  Perverted  sense  of 
smell.  As  it  is  usually  for  one  or  other  of  these  that 
the  jDatient  seeks  advice,  it  will  be  convenient  to  treat 
of  each  separately. 

I.  Obstruction  to  the  passage  of  air  through  the 
nostril  is  easily  produced  by  anything  that  causes 
swelling  of  the  lining  membrane  of  the  narrower  parts 
of  the  nasal  cavity  ;  by  displacements  of  any  part  of  the 
wall  of  the  cavity,  especially  the  septum;  by  granulation 
tissue,  and  by  new  growths  springing  from  the  wall  of 
the  cavity,  or  projecting  into  it  from  neighbouring 
parts  ;  by  foreign  bodies  introduced  into  the  nose ;  or, 
by  accumulations  of  inspissated  mucus  (crusts). 

The  obstruction  may  be  either  in  the  nose  itself,  or 
further  back  in  the  nasopharynx ;  thus,  cicatricial 
adhesions  between  the  soft  palate  and  the  back  of  the 
pharynx,  or  a  tumour  of  the  nasopharynx  may  cause  com- 
plete obstruction  to  the  passage  of  air  through  the  nares. 

Bilateral  obstruction,  affecting  both  nostrils,  is  due 


DISEASES    OF    THE    NOSE.  43 

either  to  some  nasopharyngeal  cause,  such  as  adenoids, 
or  to  some  general  cause  affecting  the  whole  nasal 
region,  such  as  general  catarrh  or  inflammation  of  the 
nose,  or  to  the  existence  of  disease  affecting  both  nostrils 
simultaneously,  such  as  multiple  polypi. 

Growths  in  the  nasopharynx,  such  as  fibromata  and 
sarcomata,  and  even  simple  mucous  polypi,  if  unusually 
large,  may  cause  marked  depression  and  bulging  of  the 
soft  palate,  easily  visible  and  palpable  from  the  mouth. 
A  finger  passed  up  behind  the  soft  palate  will  confirm 
the  diagnosis  of  a  tumour  in  that  situation. 

Unilateral  obstruction,  affecting  one  nostril  only,  may 
be  due  to 

(i)  Displacement  of  the  septum  nasi  either  from 
congenital  malformation,  or  more  commonly  from  old 
injury,  such  as  a  blow  or  fall  upon  the  nose.  Inspection 
of  the  nostrils  shows  a  red,  bulging  swelling  on  the 
affected  side,  and  corresponding  hollow  on  the  opposite 
side.  It  is  the  presence  of  this  hollow  on  the  unaffected 
side  which  serves  to  distinguish  mere  deviation  of  the 
septum  from  tumours  and  inflammatory  and  other 
swellings  of  the  septum,  for  which  at  first  sight  it  may 
be  mistaken. 

(ii)  Disease  of  the  septum,  usually  acute  or 
chronic  inflammation  (simple  abscess  or  inflammation 
due  to  syphilitic,  tuberculous,  or  other  disease  of  the 
cartilage  or  bone  of  the  septum),  occasionally  a  tumour 
originating  in  the  septum. 

In  most  of  these  cases  the  swelling  is  to  be  seen  on 
both  sides  of  the  septum.  The  absence  of  the  corre- 
sponding hollow  on  the  opposite  side  serves  to  distin- 
guish these  from  mere  deviation  of  the  septum. 

Examination  with  a  probe  shows  that  the  swelling 


44  SURGICAL   DIAGNOSIS. 

springs  from  and  is  attached  to  the  septum  ;  this  serves 
to  distinguish  septal  swellings  from  the  common  polypi 
which  practically  never  arise  in  this  structure. 

(iii)  A  foreign  body  introduced  from  without. 
Here  the  history  may  help  us,  unless  the  patient  is  a 
very  young  child  or  an  older  patient  who  either  has  no 
knowledge  of  the  introduction  of  the  foreign  body,  or 
intentionally  wishes  to  deceive  the  surgeon.  Examina- 
tion with  reflected  light  and  a  probe  will  generally 
suffice  to  reveal  the  nature  of  the  foreign  body  ;  if  it  be 
much  coated  with  mucus,  it  may  be  necessary  to  wipe 
or  wash  the  latter  away  before  the  examination  can  be 
properly  made.  Foreign  bodies  are  often  of  a  black 
colour  from  the  dried  blood  which  coats  them.  A  piece 
of  necrosed  bone  may  very  closely  resemble  a  foreign 
body  introduced  from  without. 

(iv)  Disease  of  the  soft  parts  covering  a  tur- 
binated bone,  usually  the  inferior.  The  commonest 
disease  is  a  chronic  form  of  hypertrophy  (hypertrophic 
rhinitis).  In  this  disease  the  soft  parts  covering  the 
bone  are  much  swollen,  and  form  mulberry-like  masses, 
most  marked  at  the  anterior  or  posterior  ends  of  the 
bone.  These  masses  can  be  seen  by  anterior  or  posterior 
rhinoscopy.  Sometimes  the  mucous  membrane  along 
the  whole  of  the  lower  edge  of  the  bone  forms  a  thick, 
pendulous,  fringe-like  mass. 

(v)  Polypi,  an  extreme^  common  cause  of  obstruc- 
tion. 

The  common  mucous  polypus  usually  presents  itself 
in  the  form  of  a  pale  reddish  or  greyish  mass.  Its 
colour  alone  is  usually  sufficient  to  distinguish  it  from  a 
swelling  of  the  septum  or  of  a  turbinate  bone,  which  is  of 
a  brighter  red.  Examination  with  a  probe  will  usually 
show  that  it  is  movable.     Polypi  most  commonly  spring 


DISEASES   OF   THE   NOSE.  45 

from  the  middle  turbinated  bone  and  from  tbe  upper  part 
of  the  nostril  rather  than  from  the  lower.  They  are  gene- 
rally multiple,  and  often  occur  in  both  nostrils  at  once. 
The  presence  of  a  nasal  polypus  together  with  a  purulent 
discharge  generally  indicates  disease  of  an  accessory 
sinus. 

The  far  more  serious  disease,  the  fibrous  polypus, 
or  angeio-fibroma,  as  it  is  sometimes  called,  from  the 
number  of  vessels  within  it,  presents  itself  as  a 
rounded  mass  blocking  up  the  whole  nostril  and  is  of 
a  much  deeper  red  colour  than  the  simple  mucous 
polypus.  The  fibrous  polypus  usually  grows  from  the 
roof  of  the  nostril  (base  of  the  skull),  and  is  especially 
apt  to  project  into  the  nasojoharynx.  In  this  situation 
it  can  usually  be  both  seen  and  felt.  A  tumour  of  this 
kind  is  usually  seen  in  young  adults,  and  if  allowed  to 
attain  a  considerable  size  may  cause  great  expansion  of 
the  nose,  and  absorption  of  the  neighbouring  maxil- 
lary bone.  The  displacement  of  the  facial  bones  may 
lead  to  much  external  deformity.  It  is  sometimes 
difficult  to  distinguish  a  fibroma  from  a  sarcoma  or  other 
malignant  tumour.  Nasal  fibromata,  like  most  fibro- 
mata that  are  covered  with  mucous  membrane,  have  a 
great  tendency  to  bleed.  Repeated  severe  attacks  of 
hasmorrhage  in  a  young  man  with  unilateral  nasal 
obstruction  should  always  rouse  a  suspicion  of  fibroma 
and  demand  a  careful  and  thorough  examination  of 
the  nose. 

(vi)  Malignant  tumours  that  block  up  the  nostril 
and  are  visible  on  inspection  of  the  nasal  cavity  usually 
present  as  rough,  friable,  ulcerated  masses,  that  bleed 
readily  when  touched  with  a  probe.  The  diagnosis  has 
to  be  made  by  the  short  history  and  by  the  evidence  of 
local  infiltration. 


46  SURGICAL   DIAGNOSIS. 

Malignant  tumours  of  the  nose  may  spring  not  only 
from  the  lining  membrane  of  the  nose  itself,  but  from 
the  various  bones  and  mucous  cavities  that  surround 
that  cavity.  Hence  in  the  examination  of  a  suspected 
malignant  tumour  of  the  nose  care  should  be  taken  to 
examine  the  palate,  both  hard  and  soft,  which  may 
show  distinct  evidence  of  local  infiltration  ;  the  naso- 
pharynx, which  may  reveal  the  presence  of  a  cha- 
racteristic mass  of  growth  ;  the  antrum,  in  which  such 
a  tumour  often  originates  ;  and  the  inner  part  of  the 
orbit.  Tumours  originating  in  the  upper  part  of  the 
nasal  cavity,  where  they  are  not  easily  accessible  to 
direct  examination,  will  often  betray  their  presence  to 
a  finger  pressed  deeply  into  the  inner  corner  of  the 
orbit.  The  thin  papery  bone  in  this  region  is  more 
easily  perforated  by  a  malignant  tumour  tban  the  hard 
and  thick  nasal  bones  and  nasal  processes  of  the 
superior  maxillary  bones  which  cover  its  anterior  surface. 
Lastly,  it  should  be  remembered  that  tumoursoriginating 
in  the  upper  regions  of  the  nose,  in  the  ethmoid  and 
sphenoid  bones,  for  example,  often  extend  upwards  into 
the  cranial  cavity  itself.  Cerebral  symptoms,  therefore, 
such  as  persistent  headache,  Diay  aid  in  the  diagnosis. 

11.  Discharge  of — (ct)  Mucus  ;  (h)  Pus  ;  (c)  Blood. 

(a)  Mucus. — An  increase  in  the  amount  of  mucus 
discharged  from  the  nose  occurs  in  any  condition  of 
catarrhal  inflammation  of  the  nose  or  neighbouring 
sinuses.  It  may  also  occur  in  cases  of  polypi,  in  which 
the  tumours  become  congested  or  inflamed.  It  is  not, 
as  a  rule,  a  sign  of  much  importance  ;  it  generally 
indicates  trivial  rather  than  serious  disease  of  the  nose. 

Many  cases  of  suppuration  connected  with  disease  of 
the  nose  or  accessory  sinuses  begin,  however,  with  a 


DISEASES    OF   THE   NOSE.  47 

catarrlial  mucous  discharge  which  subsequently  be- 
comes muco-purulent  and  then  purulent.  A  chronic 
mucoid  or  muco-purulent  discharge  from  both  nostrils 
in  children  is  generally  due  to  adenoid  vegetations. 
The  diagnosis  is  made  by  the  presence  of  the  other 
signs  and  symptoms  of  that  disease.  The  characteristic 
facieS;  the  habitually  half-opened  mouth,  the  nocturnal 
snoring,  sometimes  associated  with  poor  development  of 
both  mind  and  body,  together  with  the  physical  ex- 
amination of  the  nasopharynx  by  finger  or  reflected 
light,  seldom  leave  any  doubt  as  to  the  true  nature  of 
the  nasal  discharge. 

(b)  Pus. — Purulent  and  muco-purulent  discharges 
are  of  far  more  importance  than  those  which  are  merely 
mucous.  They  often  indicate  exceedingly  troublesome 
and  intractable,  if  not  actually  dangerous,  diseases.  An 
acute  muco-purulent  or  pmnilent  discharge  from  both 
nostrils  indicates  infection  by  some  micro-organism  such 
as  that  of  diphtheria,  gonorrhoea,  or  glanders.  The  com- 
moner exanthemata,  such  ms  measles  and  scarlet  fever, 
often  present  this  complication.  So  does  syphilis  in  its 
secondary  stage,  of  which  the  congenital  form,  as  in  the 
"  snuffles  "  of  infants,  affords  a  familiar  example.  If  the 
general  symptoms  of  these  various  diseases  are  not  suf- 
ficiently marked  for  the  establishment  of  a  diagnosis, 
the  history  may  afford  valuable  help,  or  bacteriological 
examination  may  reveal  the  presence  of  some  character- 
istic bacillus.  In  newly  born  infants  an  acute  nasal 
discharge  generally  means  gonorrhoea,  and  infection  has 
probably  been  conveyed  from  the  vaginal  discharges  of 
the  mother,  either  directly  at  birth,  or  indirectly  by  means 
of  an  infected  towel  or  cloth.  The  discharge  due  to 
congenital  syphilis  first  appears  a  few  weeks  after  birth. 


4^  SURGICAL   DIAGNOSIS. 

In  a  case  of  acute  purulent  nasal  discharge  it  is  not 
generally  possible  to  make  a  very  thorough  or  satis- 
factory examination.  If  the  discharge  is  gently  wiped 
or  washed  away  it  may  be  possible  to  obtain  a  view  of 
some  portion  of  the  interior  of  the  nose,  but  generally 
such  examination  had  better  be  postponed  until  the 
acuteness  of  the  discharge  has  subsided. 

It  must  never  be  forgotten  that  careless  or  injudicious 
syringing  in  a  case  of  infective  nasal  discharge  may 
drive  the  infective  material  up  the  Eustachian  tube  and 
set  up  an  acute  inflammation  of  the  middle  ear. 

With  reference  to  foul  smell  in  connection  with 
nasal  diseases,  it  may  here  be  stated  that  this  is  due 
to  the  decomposition  of  pus  and  mucus  in  the  nose. 
It  is  especially  apt  to  occur  in  cases  in  which  either  of 
these  products  is  retained  for  a  long  time  in  the  nose. 
It  is  particularly  common  in  cases  in  which  necrosed 
bone  is  present ;  in  a  child  it  sometimes  indicates  the 
presence  of  a  foreign  body. 

The  disease  known  as  atroj^hic  rhinitis  is  character- 
ised by  the  formation  of  a  small  quantity  of  nasal 
discharge  which  quickly  dries  and  produces  crusts. 
These  remaining  in  the  nose,  decompose  readily  and 
cause  a  horrible  smell  (ozoena),  which  is  the  most  notice- 
able feature  of  the  complaint. 

A  very  foetid  discharge  is  also  met  with  in  cases  of 
tertiary  syphilitic  disease.  This  disease  usually  affects 
the  septum  of  the  nose  rather  than  other  parts,  aud  is 
characterised  generally  by  the  occurrence  of  deep  ulcers 
and  considerable  tendency  to  necrosis.  Deep  ulcera- 
tion extending  through  the  palate  into  the  mouth  is 
not  uncommon,  and  is  highly  characteristic. 

A  chronic  nasal  suppuration  usually  has  its  origin  in 


DISEASES    OF    THE    NOSE.  49 

some  local  disease  of  the  nose  or  neighbouring  parts. 
It  must  always  be  borne  in  mind  that  a  purulent  nasal 
discharge  may  be  derived  not  from  disease  of  the  nose 
itself,  but  from  disease  of  any  of  the  neighbouring 
parts,  especially  the  various  accessory  cavities  (antrum, 
frontal,  ethmoidal  and  sphenoidal  sinuses). 

Moreover,  a  nasal  discharge  does  not  necessarily  pre- 
sent itself  at  the  anterior  nares,  but  may  run  backwards 
into  the  pharynx,  and  perhaps  thus  escape  observation. 

If  a  chronic  suppuration  exist,  for  which  no  cause 
can  be  found  in  the  nostril,  and  especially  if  it  be 
unilateral,  then  it  should  be  suspected  that  the  source 
is  in  one  of  the  accessory  cavities.  The  cavity  which 
is  most  often  the  seat  of  chronic  suppuration  is  un- 
doubtedly the  antrum  ;  less  commonly  affected  are  the 
frontal,  ethmoidal  and  sphenoidal  sinuses. 

The  source  of  the  discharge  can  sometimes  be  ascer- 
tained by  direct  examination.  After  cleaning  the 
nostril  with  a  cotton  wool  mop,  it  may  be  noticeable 
that  the  pus  reappears  in  a  particular  place.  Thus  if  it 
comes  from  the  middle  meatus  it  may  be  suspected  to 
be  derived  from  the  antrum  or  perhaps  the  frontal  or 
anterior  ethmoidal  sinuses,  since  these  cavities  all  open 
into  the  middle  meatus.  Similarly  pus  in  the  superior 
meatus  is  probably  derived  from  the  posterior  ethmoidal 
or  sphenoidal  sinuses. 

Local  tenderness  is  sometimes  a  guide  to  the  sinus 
affected.  A  dull  pain  in  the  cheek  may  indicate 
antral  suppuration,  pain  in  the  forehead  (brow  ague) 
may  point  to  the  frontal  sinus. 

The  pain  connected  with  sphenoidal  suppuration  is  less 
definitely  located,  but  the  patient  complains  of  headache. 

The  amount  of  pain  produced  by  suppuration  within 

D 


50  SURGICAL    DIAGNOSIS. 

the  accessory  sinuses  depends  largely  upon  whether  the 
pus  is  shut  up  within  the  cavity  or  free  to  flow  out. 
If  free  to  flow  out,  the  diagnosis  can  be  made  largely 
by  direct  observation  of  the  source  of  the  discharge. 
If  not  free,  then  the  symptoms  of  painful  distension  of 
the  sinus  are  more  marked.  In  some  severe  cases  there 
may  even  be  oedema  of  the  soft  parts  over  the  sinus, 
and  in  still  more  extreme  cases  septic  osteom3^elitis  may 
complicate  suppuration  in  these  sinuses: 

The  diagnosis  of  pus  retained  within  the  antrum  is 
sometimes  facilitated  b}^  making  the  patient  lean  his 
head  towards  the  sound  side.  A  sudden  flow  of  pus 
shows  emptying  of  the  antrum  through  the  now 
dependent  opening. 

Transillumination  is  in  many  cases  a  valuable  means 
of  detecting  suppuration  in  the  antral  or  frontal  sinuses. 
The  examination  must,    of  course,  be  made  in  the 
dark.     A  small   electric  light   is  introduced  into  the 
patient's  mouth  and   the  -  lips   are  closed.     Normally, 
much  light  is  then  seen  to  come  through  the  cheeks,  a 
triangular  area  in  the  infraorbital  region  being  espe- 
cially well  illuminated.     If  the  antrum  be  diseased,  the 
rays  of  light  will  not  pass  so  readily  through  it,  and  the 
infraorbital  region  does  not  undergo  this  illumination, 
but   remains    dark.     Failure  to    get  transillumination 
does  not,  however,  necessarily  indicate  empyema  of  the 
antrum.     Solid    growths    in    the    antrum,    thickened 
mucous  membrane,  and  other  abnormal  conditions,  may 
produce    the   same   efiect.     Even  within  the  limits  of 
health  there  is,  however,  some  variation  in  the  degree 
to  which  the  antrum  can  be  transilluminated.     Never- 
theless, taken  together  with  the  presence  of  a  chronic 
discharge  from  the  middle  meatus,  it  is  often  a  valuable 


DISEASES    OF    THE    NOSE.  51 

means  of  diagnosis.  Transillumination  may  also  be 
applied  to  the  detection  of  disease  of  the  frontal  sinns. 
In  this  case  a  small  electric  lamp  is  pressed  against  the 
soft  tissues  at  the  inner  and  upper  angle  of  the  orbit. 
The  healthy  frontal  sinus  should  then  present  as  a 
bright  patch  of  light,  while  the  diseased  one  is  not 
illuminated.  It  should  be  remembered  that  thin  pus 
may  not  affect  translucency.  Conversely  interference 
with  the  passage  of  light  often  means  diseased  mucous 
membrane,  rather  than  the  actual  presence  of  pus. 

In  many  cases  the  diagnosis  of  pus  within  the 
antrum  can  be  made  only  by  puncture.  This  is  best 
done  through  the  inner  wall  of  the  antrum  towards  the 
anterior  part  of  the  inferior  meatus  of  the  nose.  The 
puncture  should  be  made  in  a  backward  and  outward 
direction  by  means  of  a  small  straight  trocar  and 
canula. 

(c)  Blood. — Haemorrhage  from  the  nose  indicates  a 
breach  of  surface  in  some  part  of  the  mucous  lining  of 
that  cavity.  It  may  be  due  to  traumatism,  in  which 
case  it  is  of  but  little  importance  unless  of  so  severe  a 
nature  and  accompanied  by  such  other  grave  symptoms 
as  to  suggest  a  fracture  of  the  base  of  the  skull. 

Spontaneous  haemorrhage  is  not  uncommon  in 
children,  and  an  occasional  attack  does  not  necessarily 
mean  anything  serious. 

In  middle-aged  or  elderly  people  spontaneous  nasal 
haemorrhage  is  of  more  serious  import.  It  often 
betokens  serious  disease  of  such  viscera  as  the  heart, 
kidneys,  or  liver,  and  should  demand  a  careful  examina- 
tion of  these  parts.  There  are  many  general  diseases, 
too,  such  as  leucocythasmia,  hasmophilia,  and  others,  in 
which  a  tendency  to  haemorrhage  is  a  prominent  feature, 


52  SURGICAL    DIACxNOSIS. 

and  a  nasal  bleeding  may  be  the  first  indication  of  one 
of  these. 

At  any  age  a  spontaneous  and  severe  hgemorrhage 
may  indicate  the  existence  of  a  tumour  ;  in  a  young 
subject  fibroma  or  sarcoma  is  the  most  likely  form  ;  in 
an  older  person  some  form  of  carcinoma. 

As  repeated  attacks  of  spontaneous  haemorrhage  are 
often  for  a  considerable  time  the  only  obvious  signs  of 
a  tumour,  they  should  always  demand  a  careful  and 
thorough  local  examination. 

In  various  inflammatory  and  ulcerative  conditions  of 
the  nose  haemorrhage  may  occur.  In  these  cases,  how- 
ever, it  is  the  accompanying  muco-purulent  or  purulent 
discharge  that  is  the  more  prominent  and  obvious 
feature,  and  diagnosis  of  the  cause  of  the  haemorrhage 
does  not  usually  present  any  difficulty. 

III.  A  perverted  sense  of  smell  may  be  due  to 
disease  either  of  the  nose  itself  or  of  the  central  nervous 
system.  Local  disease  or  foul  discharges  may  cause  a  bad 
smell  to  be  noticed  by  the  patients.  Frequently,  how- 
ever, a  foul  smell  which  is  very  noticeable  and  disagree- 
able to  others,  is  unnoticed  by  the  patient  himself,  owing 
to  the  disease  having  affected  the  olfactory  nerve  end- 
ings.    This  is  especially  the  case  with  atrophic  rhinitis. 

If  a  patient  complains  of  any  alteration  in  the  sense 
of  smell,  a  very  careful  local  examination  of  the  interior 
of  the  nose  should  first  be  made.  If  no  evidence  of 
disease  can  be  discovered,  then,  and  then  only,  is  it  per- 
missible to  consider  that  the  central  nervous  system 
itself  may  be  at  fault.  The  diagnosis  has  then  to  be 
made  by  the  existence  of  other  signs  and  symptoms  of 
cerebral  disease. 


CHAPTER  V. 

DISEASES  OF  THE  EAR, 

Patients  who  are  the  subjects  of  disease  of  the  ear 
usually  seek  advice  on  account  of  one  or  other  of  the 
following  conditions  : 

1.  Some  affection  of  the  external  ear  (auricle)  such 
as  deformity,  swelling,  inflammation,  ulcer,  &c. 

2.  Discharge  from  the  meatus. 

3.  Deafness. 

4.  Noise  in  the  ear  (tinnitus). 

5.  Pain. 

Each  of  these  may  be  considered  separately. 

1 .  Affections  of  the  auricle  differ  in  no  essential  par- 
ticular from  those  of  the  skin  and  cellular  tissue  in 
other  parts  of  the  body,  and  need,  therefore,  no  detailed 
description. 

2.  Discharge  from  the  meatus  is  usually  purulent, 
and  often,  from  decomposition,  has  a  foul  odour.  It 
may  be  derived  from  any  inflammatory  condition  of  the 
delicate  skin  lining  the  meatus,  such  as  eczema.  It  may 
have  a  more  deep-seated,  and,  consequently,  more  serious 
origin  in  disease  of  the  bony  wall  of  the  meatus 
(necrosis,  caries).  Most  often,  however,  when  profuse 
and  of  long  standing,  it  comes  from  the  middle  ear, 
escaping  through  a  perforation  in  the  membrane,  and  is 


54  SURGICAL   DIAGNOSIS. 

indicative  of  inflammatory  trouble  of  the  wall  of  that 
cavity,  or  of  its  associated  chamber,  the  mastoid  antrum. 
The  source  of  the  discharge  must  be  ascertained  by 
direct  examination  with  the  speculum. 

3.  Deafness  may  be  due  to — 

(a)  A  mere  obstruction  in  the  meatus,   such  as   a 

swelling,  inflammatory  or  otherwise,  springing 
from  the  wall  of  the  meatus  ;  or  a  foreign 
body,  such  as  a  bead  or  a  pea,  or  other  sub- 
stance introduced  from  without ;  or  an  accu- 
mulation of  wax. 

(b)  Something    which   interferes    with  the   normal 

vibration  of  the  membrana  tympani,  or  with 
the  mechanism  in  the  middle  ear  (ossicles,  &c.) 
which  serves  to  conduct  the  vibrations  of 
sound  to  the  internal  ear.  Obstruction  of  the 
Eustachian  tube,  by  preventing  free  access  of 
air  to  the  middle  ear,  and  disease  of  the  mem- 
brane itself  (chronic  inflammatory  thickening, 
perforation,  &c.)  are  thus  common  causes  of 
deafness. 

(c)  Affections  of   the  internal  ear  itself   or   of  its 

associated  auditory  nerve,  or  even  of  the  brain 
itself  (nerve  deafness).  The  use  of  the  tuning 
fork  (see  page  61)  is  a  valuable  aid  in  the 
differential  diagnosis  between  deafness  due 
to  disease  of  the  nervous  portion  of  the  ear 
and  that  due  to  some  fault  in  the  external  or 
conducting  portion  of  the  organ. 

4.  Noises  in  the  ear  (tinnitus)  are  due  to  irritation  of 
almost  any  part  of  the  organ  of  hearing ;  thus,  a  mass 
of  wax  in  contact  with  the  membrane,  an  inflammation 
of  the  middle  ear,  or  an  affection  of  the  auditory  nerve 


DISEASES    OF   THE   EAR.  55 

or  braiu,  may  give  rise  to  this  symptom.  Its  presence 
should  demand  a  very  careful  examination  of  the  ear, 
that  the  cause  of  the  irritation  may,  if  possible,  be 
ascertained  and  removed.  It  is  frecpiently  a  most 
troublesome  and  intractable  symptom. 

5,  Pain  is  most  severe  when  it  is  due  to  inflammation 
causing  tension.  Thus  a  minute  abscess  or  boil  between 
the  bony  wall  of  the  meatus  and  its  lining  may  cause 
excruciating  pain  ;  inflammation  of  the  middle  ear  or  of 
the  antrum,  or  of  any  part  of  the  surrounding  bone,  may 
likewise  be  productive  of  much  pain,  which  is  severe  in 
proportion  to  the  intensity  of  the  inflammation  and  the 
tension  of  the  inflammatory  products. 

Ulceration  of  the  middle  ear  does  not  usually  in  itself 
cause  pain,  provided  that  there  is  a  free  vent  for  the 
discharge  through  a  perforated  membrane.  But  when 
such  discharge  is  pent  up,  or  when  the  dense  surround- 
ing bone  is  involved  in  the  inflammatory  process,  paiu 
becomes  a  prominent  feature. 

Tenderness  over  the  mastoid  process  is  a  common 
accompaniment  of  deep-seated  inflammation  of  the 
middle  ear,  involving  the  mastoid  antrum. 

It  must  not  be  forgotten  that  a  pain  felt  in  the  ear 
may  be  a  referred  pain  clue  to  disease  in  some  other 
part;  of  this,  the  common  pain  in  the  ear  due  to  a 
carious  wisdom  tooth  affords  a  good  example. 

Physical  Examination  of  the  Ear. 

The  examination  of  affections  of  the  auricle,  which  is 
accessible  to  direct  inspection  and  palpation,  requires 
no  special  description. 

The  mastoid  region  should  be  examined  to  see  if  it 


56  SURGICAL   DIAGNOSIS. 

presents  any  evidence  of  inflammation,  such  as  redness, 
oedema,  or  tenderness. 

The  meatus  must  be  examined  by  direct  inspection, 
usually  by  means  of  a  speculum  and  reflected  light. 

If,  as  is  often  the  case,  the  meatus  is  obstructed  by 
wax  or  by  discharge  from  the  ear,  these  may  have  to  be 
removed  by  gentle  syringing  or  sponging  with  cotton 
wool  before  the  meatus  can  be  thoroughly  inspected. 

In  the  introduction  of  a  speculum,  due  regard  should 
be  had  to  the  curved  shape  of  the  meatus,  and  this  tube 
should  be  straightened  as  regards  its  cartilaginous  part 
by  gentle  traction  on  the  auricle.  This  traction  should 
be  made  upwards  and  backwards  in  the  case  of  an  adult, 
directly  backwards  in  that  of  a  child. 

In  syringing  the  meatus  the  nozzle  of  the  syringe 
should  be  directed  upwards,  so  that  the  stream  of  warm 
fluid  impinges  against  the  roof  of  the  meatus  and  not 
directly  against  the  membrana  tympani.  Masses  of 
wax  and  other  foreign  bodies  are  generally  easily  recog- 
nised by  their  colour,  and  if  necessary  by  touching  with 
a  probe.  Narrowing  of  the  meatus  by  inflammatory 
swelling  of  the  soft  parts  of  its  wall  is  generally  easily 
recognised  by  the  smallness  of  the  aperture,  and  by  the 
tenderness  and  other  signs  of  inflammation. 

Narrowing  of  the  meatus  by  bone  is  generally  due  to 
some  chronic  inflammatory  affection  of  the  surrounding 
bone,  very  rarely  to  genuine  exostosis. 

Swelling  of  the  wall  of  the  meatus  may  entirely 
obscure  the  membrane  and  prevent  any  inspection  of  it. 

Much  with  regard  to  disease  of  the  ear,  and  especially 
of  the  middle  ear,  may  be  learnt  by  simple  inspection 
of  the  membrana  tympani. 

Itshouldbe  remembered  that  themembraneis  situated. 


DISEASES    OF   THE   EAR.  57 

not  transversely,  but  obliquely  across  the  bottom  of  the 
meatus,  the  upper  and  posterior  borders  being  nearer  to 
the  observer  than  are  the  lower  and  anterior. 

The  normal  membrane  has  a  bluish  grey  colour  with 
a  silvery  lustre  ;  the  latter  is  most  marked  at  the  lower 
and  anterior  part,  where  there  is  in  health  a  bright, 
shiny,  triangular  area. 

Kunning  downwards  and  backwards  to  near  the 
centre  of  the  membrane  is  the  long  process  (handle)  of 
the  malleus,  while  at  the  upper  end  of  this  is  a  slight 
projection,  the  short  process.  Passing  backwards  and 
forwards  from  this  short  process  are  two  faintly  marked 
ridges,  the  longitudinal  folds. 

We  have  to  notice  the  colour  of  the  membrane  and  its 
lustre,  the  presence  of  perforations  in  it,  and  of  polypi 
or  granulations  springing  from  it. 

Further,  the  degree  of  concavity  or  convexity  of  the 
membrane  affects  the  obliquit}^  of  the  handle  of  the 
malleus  and  the  prominence  of  the  short  process  and 
longitudinal  folds,  and  thus  afford  valuable  evidence  of 
obstruction  to  the  Eustachian  tube. 

Recent  acute  inflammation  of  the  membrane  causes 
naturally  increased  vascularity  and  loss  of  lustre.  The 
handle  of  the  malleus  is  at  the  same  time  more  or  less 
obscured  from  view.  Chronic  inflammation  of  the 
membrane  leads  to  thickening  of  it  and  loss  of  both 
lustre  and  transparency,  so  that  the  handle  of  the 
malleus  is  much  less  visible. 

The  apparent  colour  of  the  membrane  when  trans- 
parent is  naturally  affected  by  the  colour  of  whatever 
lies  behind  it.  Thus,  if  the  middle  ear  be  full  of  pus  a 
yellow  colour  is  imparted  to  the  membrane. 

A  collection  of  fluid,  partially  filling  the  middle  ear, 


5  8  SURGICAL    DIAGNOSIS. 

may  be  easily  visible  through  the  membrane  and  is 
recognised  by  its  horizontal  upper  border  marking  the 
upper  limit  of  the  fluid.  This  line  naturally  remains 
horizontal  when  the  ear  is  inclined  forwards  or  back- 
wards, and  the  alteration  thus  produced  in  its  relations 
to  the  various  parts  of  the  membrane  affords  a  ready 
means  of  detecting  its  nature. 

An  unusually  thin  membrane  may  derive  a  reddish 
colour  from  the  inner  wall  of  the  tympanum,  visible 
through  the  membrane.  The  thin  portion  of  membrane 
that  covers  a  healed  perforation  may  thus  have  a  reddish 
colour,  and  may  resemble  in  this  respect  a  perforation 
itself,  which  allows  the  mucous  membrane  of  the  inner 
wall  to  be  directly  visible. 

A  thin  portion  of  membrane  will  alter  in  colour  if  air 
be  injected  through  the  Eustachian  tube ;  the  thin 
portion  then  becomes  distended  and  convex  out- 
wardlv.' 

A  polypus  or  polypoid  granulation  springing  from 
the  membrana  tympani,  or  coming  through  it,  may  from 
its  red  colour  resemble  to  a  certain  extent  a  perforation, 
but  can  usually  be  distinguished  without  difficulty  by 
touching  it  with  a  probe. 

In  cases  of  extensive  destruction  of  the  membrane, 
the  inner  wall  of  the  tympanum  may  be  freely  exposed, 
the  membrane  being  represented  merely  by  a  narrow 
ring  at  its  periphery.  In  some  of  these  cases  the 
ossicles  are  more  or  less  exposed  to  view,  in  others  they 
have  entirely  disappeared. 

Inflation  of  the  middle  ear  as  a  means  of 
diagnosis. — Much  valuable  information  may  be  ob- 
tained by  observing  the  appearance  of  the  membrane 
before  and  after  inflation  of  the  middle  ear,  especially 


DISEASES   OF   THE   EAR.  59 

in  cases  in  which  there  is  some  obstruction  to  the  Eus- 
tachian tube. 

An  obstruction  in  the  Eustachian  tube  leads  to  the 
absorption  of  the  air  in  the  middle  ear  and  consequent 
indrawing  of  the  membrane.  A  thin  portion  of  the 
membrane  may  be  more  yielding,  and  consequently 
more  indrawn  than  the  rest.  After  inflation,  the 
indrawn  membrane  or  any  portion  of  it  tends  to  become 
less  concave  or  even  convex.  Inflation  of  the  middle 
ear  may  in  some  cases  be  performed  by  simpty  directing 
the  patient  to  close  the  mouth  and  nostrils  firmly  and 
then  to  blow  hard.  Air  is  thus  forced  along  the  Eus- 
tachian tube  into  the  middle  ear  and  the  patient  is  con- 
scions  of  a  click  in  the  ear. 

More  often  inflation  is  performed  by  Politzerisation. 
The  patient  is  directed  to  take  a  mouthful  of  water  and 
hold  it  in  his  mouth  with  the  lips  closed.  One 
nostril  is  closed  and  into  the  other  is  inserted  the 
nozzle  of  an  india-rubber  tube  having  a  bag  at  the  other 
end. 

At  a  given  signal  the  patient  swallows,  while  the 
surgeon  at  the  same  time  squeezes  the  bag  sharply  and 
air  passes  along  the  Eustachian  tube  which  has  been 
opened  hy  the  act  of  swallowing. 

In  other  cases  where  these  methods  have  not  suc- 
ceeded, it  may  be  necessary  to  inject  the  air  directly 
into  the  tube  by  means  of  a  Eustachian  catheter. 
An  auscultation  tube  passing  from  the  ear  of  the 
patient  to  that  of  the  surgeon  is  used  at  the  same  time. 
To  pass  a  Eustachian  catheter,  the  well-lubricated 
instrument  should  be  passed  with  the  point  down- 
wards along  the  floor  of  the  nostril  till  it  can  be 
felt  to  impinge  against  the  posterior  wall  of  the  pharynx. 


6o  SURGICAL    DIAGNOSIS. 

The  point  should  then  be  rotated  inwards  and  the 
catheter  withdrawn  a  little  until  the  curved  end  can 
be  felt  to  hook  against  the  posterior  edge  of  the 
septum  of  the  nose.  The  operator  should  then  rotate 
outwards  the  end  of  the  catheter,  through  a  little  more 
than  half  a  circle,  and  again  push  it  gently  forwards. 
The  point  of  the  catheter  will  then  usually  be  found  to 
have  entered  the  orifice  of  the  Eustachian  tube.  Air  or 
other  fluid  can  then  be  injected  through  a  tube  or 
syringe  attached  to  the  catheter.  In  passing  a  Eus- 
tachian catheter  the  utmost  gentleness  should  be 
employed. 

It  should  be  added  that  in  some  cases  deflection  of 
the  nasal  septum  interferes  with  the  passage  of  a 
catheter.  In  a  troublesome  case  the  introduction  of 
the  Eustachian  catheter  may  be  aided  by  vision  by 
means  of  a  speculum  and  reflected  light. 

The  following  conclusions  may  be  drawn  from  the 
effects  of  Politzerisation.  If  no  sound  be  heard  in  the 
affected  ear  by  the  patient  at  the  moment  of  infla- 
tion, if  no  alteration  be  produced  in  the  appearance 
of  the  membrane,  and  if  no  improvement  in  the 
hearing  follow,  then  it  is  probable  that  the  Eus- 
tachian tube  is  completely  obstructed. 

Bubbles  of  air  visible  in  the  middle  ear  after  infla- 
tion indicate  the  presence  of  fluid  in  that  cavity.  A 
whistling  noise  heard  at  the  moment  of  inflation  indi- 
cates a  perforation  of  the  membrane.  In  order  to 
hear  this  whistling  best,  the  ears  of  the  surgeon  and 
patient  should  be  connected  by  an  india-rubber  tube. 

Lessening  of  the  concavity  of  the  membrane  as  shown 
by  diminution  in  the  prominence  of  the  short  process 
of  the  malleus  and  of  the  posterior  fold,  and  altera- 


DISEASES    OF    THE    EAR.  6 1 

tiou  in  the  inclination  of  the  handle  of  the  malleus, 
indicate  an  indrawn  membrane.  This  in  its  turn 
indicates  some  obstruction  to  the  Eustachian  tube. 

The  conversion  of  local  dark  areas  on  the  membrane 
into  light  areas  indicates  that  locally  depressed  areas 
have  become  converted  into  convex  prominences 
and  show  the  existence  of  areas  of  thin  membrane, 
healed  perforation,  &c. 

Use  of  the  tuning-fork. — Apart  from  its  use 
as  a  mere  test  of  the  amount  of  hearing  present,  the 
great  use  of  the  tuning-fork  is  in  the  diagnosis  between 
deafness  due  to  the  internal  ear  and  central  nervous 
system,  and  that  which  is  due  to  obstruction  in,  or 
disease  of,  the  conducting  apparatus. 

Normally,  in  a  healthy  person  the  vibrations  of  a 
tuning-fork  can  be  heard  not  only  when  placed  opposite 
the  ear,  but  also  when  placed  on  the  top  of  the  head, 
on  the  chin,  or  between  the  teeth.  When  in  the  latter 
situations,  some  of  the  vibrations  are  conducted  directly 
along  the  bones  of  the  head  to  the  internal  ear  and 
there  produce  the  sensation  of  hearing.  Normally  a 
tuning-fork  can  be  heard  opposite  the  ear  after  it  has 
ceased  to  be  heard  on  the  vertex.  That  is,  the  vibra- 
tions are  still  carried  to  the  ear  by  means  of  the 
conducting  apparatus,  meatus,  membrane  and  ossicles. 
If  there  be  an  obstruction  to  the  conducting  appa- 
ratus, e.g.,  a  lump  of  wax  in  the  meatus,  then  the 
tuning-fork  on  the  vertex  is  heard  better  in  the 
affected  ear  than  in  the  sound  one  ;  the  tuning-fork 
held  opposite  the  ear  is  naturally  not  heard  so  well  on 
the  affected  as  on  the  sound  side  (Weber's  test). 

The  reason  for  all  this  is  obvious.  The  tuning-fork  on 
the  vertex  transmits  vibrations  along  the  bone  to  the  ear ; 


62  SURGICAL    DIAGNOSIS. 

some  of  these  pass  to  the  internal  ear,  others  pass  out- 
wards and,  if  there  is  no  obstruction,  are  lost.  If, 
however,  there  is  an  obstruction,  these  latter  vibrations 
are  reflected  inwards  and  pass  to  the  internal  ear,  re- 
inforcing those  which  have  gone  directly  to  it  through 
the  bone. 

In  cases  of  deafness  due  to  disease  of  the  internal 
ear,  auditory  nerve,  or  brain,  the  vibrations  of  a  tuning- 
fork  on  the  vertex  are  either  not  heard  at  all,  or  they 
are  heard  less  plainly  on  the  affected  than  on  the  un- 
affected side  of  the  head.  It  must  be  remembered, 
however,  that  the  hearing  of  a  tuning-fork  placed  upon 
the  vertex  varies  considerably  in  different  individuals 
even  within  the  limits  of  health.  Weber's  test  is  natu- 
rally most  useful  in  cases  of  unilateral  deafness. 

Another  test  is  that  of  Einne,  in  which  the  tuning- 
fork  is  placed  upon  the  mastoid  process  and  the  hearing 
by  absolute  bone  conduction  compared  with  that  obtained 
when  the  tuning-fork  is  held  opposite  the  meatus. 

If  the  surgeon's  own  hearing  is  normal  he  may 
estimate  the  degree  to  which  the  patient's '  hearing  by 
bone  conduction  is  impaired  by  placing  the  fork  upon 
the  patient's  mastoid  until  the  vibrations  can  no  longer 
be  heard.  He  then  immediately  transfers  it  to  his 
own  mastoid  and  notices  the  further  time  during  which 
the  vibrations  are  still  audible  to  himself. 

Intracranial   Complications  of  Middle -ear 

Disease. 

Complications  by  no  means  uncommon  in  the  later 
stages  of  suppurative  disease  of  the  middle  ear  are 
those    which    are   due   to   the    extension    of    inflam- 


DISEASES    OF    THE    EAR.  63 

mation  through  the  temporal  bone  to  the  interior  of 
the  cranial  cavity.  On  account  of  their  ser  ousness 
and  the  great  danger  to  life  which  they  involve,  they 
are  of  the  utmost  importance.  Not  only  the  aural 
specialist  but  the  general  surgeon  and  physician  should 
be  thoroughly  familiar  with  their  symptoms  in  order 
that  effective  treatment  may  be  adopted  at  the  earliest 
possible  period. 

Complications  of  ear  disease  which  are,  and  remain, 
limited  to  the  ear  itself  and  neighbouring  petrous 
bone,  although  serious  enough  as  regards  hearing, 
and  sometimes  as  regards  the  production  of  facial 
paralysis,  are  but  rarely  in  themselves  dangerous  to 
life. 

It  is  quite  otherwise,  however,  with  intracranial 
complications,  which  only  too  often  lead  to  the  death  of 
the  patient.  The  subject  is,  moreover,  an  important 
one,  owing  to  the  insidious  nature  of  the  symptoms,  the 
difficulties  of  diagnosis  and  the  ease-  with  which  they 
may  be  overlooked.  With  the  possible  exception  of 
certain  rare  cases  of  pygemic  secondary  abscesses  of  the 
brain,  which  may  have  no  direct  communication  with 
the  ear,  intracranial  complications  of  middle-ear  dis- 
ease are  always  due  to  direct  extension  of  inflamma- 
tion from  the  ear  to  the  interior  of  the  cranial  cavity. 
The  suppurative  jDrocess  may  have  led  to  gradual 
erosion  of  the  surrounding  bone  until  the  cranial  cavity 
has  been  actually  perforated.  The  thin  roof  of  the 
tympanic  cavity  is  frequently  perforated  in  this 
manner.  Or  the  inflammation  may  spread  along  one 
of  the  numerous  small  bony  channels  which  run  in 
various  parts  of  the  petrous  bone.  Thus  the  canal  of 
the  auditory  nerve,  or  the  canals  transmitting  smaller 


64  SURGICAL    DIAGNOSIS. 

nerves   or  veins,  may  be   the  paths   along  which  the 
suppuration  extends. 

Intracranial  complications  of  middle-ear  disease  may 
for  clinical  purposes  be  divided  into  three  groups. 

1.  Abscess  of  the  brain  (temporo-sphenoidal  or 
cerebellar). 

2.  Infective  thrombosis  of  the  lateral  sinus. 

3.  Meningitis  (general  or  local,  including  sub- 
dural abscess). 

A  well-marked  uncomplicated  case  of  each  of  these 
affections,  but  especially  of  the  first  two,  has  usually 
distinctive  and  easily  recognisable  symptoms.  The 
diagnosis  in  such  cases  is  not  difficult.  Frequently, 
however,  two  or  even  all  three  of  these  conditions  co- 
exist, and  the  characteristic  symptoms  of  one  are 
masked  by  those  of  another.  It  often  becomes  a  very 
difficult  problem  to  unravel  the  symptoms  and  to  say 
how  far  they  point  to  one  or  other  of  these  conditions. 

Thus  a  localised  meningitis  is  frequently  present 
both  with  abscess  of  the  brain  and  with  lateral  sinus 
thrombosis ;  a  diffuse  meningitis  not  uncommonly 
complicates  the  later  stages  of  cerebral  abscess. 

With  very  rare  exceptions,  the  intracranial  com- 
plications of  middle-ear  disease  do  not  supervene 
except  in  connection  with  chronic  and  long-continued 
disease  of  the  ear.  A  history  of  otitis  media  extending 
over  at  least  several  mouths,  or  other  evidence  of 
chronic  disease,  are  important  factors  in  the  diagnosis. 

That  the  suppurative  process  has  spread  from  the 
temporal  bone  to  the  interior  of  the  cranium  may 
often  be  suspected  by  the  abrupt  cessation  of  a  chronic 
discharge  from  the  ear,  especially  if  this  cessation  of 
discharge  be  accompanied  by  increased  pain,  by  head- 


DISEASES    OF    THE    EAR.  65 

ache,  by  a  rigor,  by  vomiting,  or  by  drowsiness. 
In  the  earlier  stages  of  intracranial  suppuration,  what- 
ever form  it  may  assume,  there  is  often  some  elevation 
of  temperature. 

Abscess  of  the  Brain. 

The  characteristic  symptoms  upon  which  we  may 
rely  in  the  diagnosis  of  abscess  of  the  brain  are : 
(i)  Mental  dulness  and  apathy  passing  onto  drowsiness 
and  then  to  unconsciousness.  (2)  A  temperature  which, 
although  at  first  perhaps  somewhat  raised,  soon  begins 
to  fall  below  normal.     (3)  A  slow  pulse. 

A  steadily  falling  subnormal  temperature 
and  pulse,  together  with  increasing  drowsi- 
ness, occurring  in  a  patient  who  is  the  sub- 
ject of  chronic  otitis  media  are  in  themselves 
sufiB-cient  for  the  establishment  of  the  diag- 
nosis of  an  intracranial  abscess. 

Vomiting  and  optic  neuritis,  symptoms  of  any  cere- 
bral tumour,  are  likewise  common  symptoms  of  cere- 
bral abscess  but  are  not  necessary  for  the  diagnosis. 

Paralytic  symptoms,  such  as  weakness  of  the  muscles 
of  one  side  of  the  face,*  of  one  arm  or  leg,  are  late 
symptoms  met  with  in  cases  of  large  abscess.  In  the 
diagnosis  of  abscess  of  the  brain  at  the  stage  at  which 
alone  treatment  is  likely  to  be  effective,  they  are 
therefore  seldom  met  with.  Convulsions,  rigidity, 
muscular  twitchings,  sighing  respiration,  and  other 
grave  symptoms  may  also  occur  at  very  late  stages  of 
the  disease,  and  indicate  extension  of  the  abscess  into 

*  Provided  that  it  is  not  due  to  involvement  of  the  trunk  of  the 
facial  nerve  in  the  disease  of  the  middle  ear  itself, 

E 


66  SUEGICAL   DIAGNOSIS. 

the  ventricle  or  on  to  the  surface  of  the  brain  ;  they  are 
on  this  account  of  little  value.  Abscess  of  the  brain 
in  connection  with  otitis  media  occurs  almost  invariably 
either  in  the  tempore- sphenoidal  lobe  or  in  the  cere- 
bellum. If  the  roof  of  the  tympanic  cavity  be  the 
point  at  which  the  pus  has  penetrated  the  cranium, 
then  the  superjacent  tempore- sphenoidal  lobe  is  the 
part  in  which  the  resulting  abscess  will  be  found. 
If  the  posterior  wall  of  the  petrous  bone  be  the  seat 
of  the  perforation,  then  the  cerebellum,  which  lies  in 
contact  with  it,  will  become  the  seat  of  the  abscess. 
Perforation  of  the  posterior  wall  leads,  however,  more 
often  to  suppurative  thrombosis  of  the  lateral  sinus 
than  to  cerebellar  abscess. 

Localisation  of  Abscess  of  the  Brain. 

Even  when  the  diagnosis  of  abscess  of  the  brain  has 
been  made,  it  may  be  an  extremely  difficult  matter  to 
decide  where  the  abscess  is  situated.  In  the  vast 
majority  of  cases,  as  already  mentioned,  the  abscess 
may  be  assumed  to  be  in  the  temporo-sphenoidal  lobe 
or  in  the  cerebellum.  Whether  the  right  or  left  side 
be  affected  is  a  matter  generally  determined  by  the 
pain,  discharge,  and  other  local  manifestations  of  disease 
of  the  ear.  But  sometimes,  when  both  ears  are  affected 
to  an  equal  extent,  or  when  the  patient  is  unconscious 
and  no  history  is  obtainable,  there  may  be  great  diffi- 
culty in  determining  the  side  on  which  the  abscess  is 
situated.  The  presence  of  optic  neuritis  more  marked 
in  one  eye,  or  the  involvement  of  a  cranial  nerve,  may 
be  of  assistance. 

If  any  paralysis  of  the  face,  arm,  or  leg  be  present, 


DISEASES   OF   THE   EAR.  67 

it  will  be  found  on  the  side  opposite  to  the  abscess  if 
the  latter  is  in  the  temporo-sphenoidal  lobe,  on  the 
same  side  if  it  be  in  the  cerebellum. 

The  diagnosis  between  cerebellar  and  temporo- 
sphenoidal  abscess  is  often  most  difficult.  Severe  oc- 
cipital headache  points  to  the  cerebellum.  Vomiting, 
too,  is  more  often  marked  in  the  cerebellar  abscess. 
There  may  also  be  obvious  inco-ordination  of  move- 
ment. The  staggering  gait  of  cerebellar  disease  is 
well  known,  but  is  by  no  means  invariably  present. 
.  A  valuable  sign  of  cerebellar  disease,  and  one  which 
indicates  the  side  on  which  the  lesion  is  situated,  is  the 
following.  The  patient  is  asked  to  stretch  his  arms 
out  in  front  of  him  and  to  perform  rapid  rotatory 
movements  of  both  hands  simultaneously.  The  hand 
of  the  side  on  which  the  cerebellar  disease  is  situated 
will  not  be  able  to  execute  this  movement  so  readily  as 
the  opposite  one.  If  the  patient  is  then  directed  to 
quickly  raise  both  arms  above  his  head,  and  to  continue 
the  rotatory  movements,  the  hand  of  the  affected  side 
is  waved  about  ,  in  an  irregular  manner,  while  the 
opposite  hand  continues  to  rotate  as  before. 

Careful  examination  of  the  middle  ear  itself  will  often 
afford  valuable  evidence  as  to  the  situation  of  the 
abscess  by  indicating  the  part  in  which  the  perforation 
of  its  wall  has  taken  place.  Thus  it  may  be  possible  to 
pass  a  bent  probe  up  through  a  perforation  in  the  roof 
of  the  tympanum.  This  would  indicate  strongly  that 
the  abscess  was  in  the  temporo-sphenoidal  lobe  rather 
than  the  cerebellum.  Owing  to  the  greater  thickness 
of  the  posterior  wall  of  the  tympanum  it  is  seldom 
possible  to  pass  a  probe  through  the  perforation  that 
leads  to  the  cerebellar  abscess. 


68  SURGICAL   DIAGNOSIS. 

Infective  Thrombosis  of  the  Lateral 
Sinus. 

The  symptoms  of  this  affection  are  usually  exceed- 
ingly characteristic.  They  are  those  of  acute  septic 
poisoning  and  are  similar  to  those  of  suppurative 
thrombosis  of  any  other  large  vein. 

Rapid  and  great  elevation  of  temperature, 
with  frequent  and  marked  remissions,  in 
which  the  temperature  falls  below  normal ; 
rapidity  of  pulse,  frequent  and  severe  rigors, 
sweats,  restlessness  and  excitability,  often 
delirium,  together  with  the  early  onset  of 
pulmonary  symptoms  denoting  general  septic 
infection,  are  the  symptoms  characteristic  of  this 
severe  and  very  fatal  complication  of  middle-ear  disease. 

Tenderness  and  perhaps  swelling  along  the  course  of 
the  internal  jugular  vein  often  aid  in  the  diagnosis,  but 
it  must  be  remembered  that  in  many  cases  of  chronic 
disease  the  lymphatic  glands  between  the  angle  of 
the  jaw  and  the  mastoid  process  are  inflamed.  The 
swelling  and  tenderness  thus  caused  may  readily  be 
mistaken  for  those  of  thrombosis  of  the  upper  part 
of  the  jugular  vein. 

Meningitis. 

The  symptoms  of  meningitis  vary  greatly  according 
to  the  severity  of  the  disease  and  its  situation.  Its 
onset  is  usually  insidious  and  may  easily  be  over- 
looked. Persistent  headache  and  delirium  are  two  of 
its  most  constant  symptoms.  Vomiting,  optic  neuritis, 
irregularity  of  pulse,  slight  or  considerable  elevation  of 
temperature,  affections  of  various  cranial  nerves,  may 


DISEASES   OF   THE    EAR.  69 

all  of  them  be  present ;  but,  on  the  other  hand,  any 
one  or  all  of  them  may  be  absent. 

When  the  meningitis  affects  the  base  of  the  brain, 
the  cranial  nerves  are  most  likely  to  be  affected. 
Meningitis  affecting  the  posterior  fossa  is  especially  apt 
to  give  rise  to  rigidity  of  the  muscles  of  the  neck  and 
retraction  of  the  head,  which  thus  become  important 
elements  in  the  diagnosis. 

A  localised  meningitis  of  the  dura  mater  is  often 
accompanied  by  collection  of  pus  between  the  dura 
mater  and  the  bone.  In  such  a  case,  grndually  in- 
creasing drowsiness  becomes  a  prominent  feature. 


CHAPTER  VI. 

INABILITY  TO  OPEN  THE  MOUTH. 

In  investigating  a  case  in  which  the  above  is  the  most 
prominent  feature,  attention  should  be  directed  first  of 
all  to  the  soft  structures  (muscles  and  others)  which  con- 
nect the  two  jaws,  since  it  is  in  these  parts  that  the 
cause  of  the  trouble  is  most  likely  to  exist. 

By  far  the  most  common  cause  of  inability  to  open 
the  mouth  is  inflammation  of  the  soft  parts  around  the 
muscles  of  the  lower  jaw  (generally  connected  with  bad 
teeth),  or  the  results  of  such  inflammation. 

Spasmodic  contraction  of  the  muscles  often  accom- 
panies the  inflammation.  In  the  acute  stage  of  the 
inflammation,  while  pain  and  swelling  are  present,  and 
probably  a  recent  history  of  dental  trouble  is  fresh  in 
the  patient's  mind,  there  is  but  little  difliculty  in 
diagnosis.  Much  more  obscure  are  those  cases  in  which 
all  evidence  of  acute  inflammation  has  subsided.  There 
is  no  evidence  of  dental  trouble,  no  swelling  can  be 
detected  anywhere,  and  yet  the  jaws  are  firmly  clenched 
together  and  cannot  be  separated.  In  such  cases  careful 
attention  to  the  history  will  frequently  point  to  dental 
trouble  of  one  kind  or  another,  and  it  may  become 
obvious  that  the  present  closure  of  the  jaws  is  due  to 
fixation  of  muscles  owing  to  the  organisation  of  inflam- 
matory products  in  and  around  them. 


INABILITY   TO    OPEN    THE    MOUTH.  7 1 

Inflammation  due  to  causes  other  than  those  con- 
nected with  the  teeth  may  lead  to  a  similar  closure  of 
the  jaws.  Thus  a  gumma,  or  other  inflammatory 
swelling  in  any  one  of  the  muscles  of  mastication,  may 
cause  closure  of  the  jaws.  Earely  a  tumour  situated  in 
one  of  the  muscles  may  produce  the  same  effect. 

A  thorough  examination,  then,  of  the  temporal  fossa3 
and  of  the  regions  of  the  masseter  and  pterygoid  muscles 
should  be  made  in  every  case  of  closure  of  the  jaws. 

Ulceration   inside   the   cheek  or  pharynx    and   the 
scarring   consequent    upon    the    ulceration,    are    also 
common  causes  of  closure  of  the  jaw.     Inflammatory 
induration  round  an  ulcer,  or  the  fibrous  tissue  of  a 
healed  ulcer,  can  generally  be  detected  without  difficulty 
by  passing  a  finger  inside  the  cheek.     Old  cicatricial 
bands,  the  result  of  cured  cancrum   oris,  afibrd  good 
examples  of  this  mode  of  closure  of  the  jaws  in  children. 
In  elderly  patients  the  possibility  of  the  existence  of 
malignant  disease  at  the  back  of  the  mouth  must  not  be 
overlooked.     Owing  to  the  firm  closure  of  the  jaws,  it 
may  be  quite  impossible  to  make  a  satisfactory  examina- 
tion of    the  mouth,  and   to  see   or  feel  the  growth. 
Careful  examination  from  the  outside  in  the  neighbour- 
hood of  the  angle  of  the  jaw  may,  however,  lead  to  the 
detection  of  deep-seated  induration  indicative  of  malig- 
nant disease.     Or  the  presence  of  enlarged  glands  in 
this  situation  may  point  in  the  same  direction. 

After  the  muscles  and  other  soft  parts  have  been 
carefully  examined  and  no  cause  for  the  closure  has 
been  detected,  the  temporo-maxillary  articulation  may 
be  examined.  The  cause  of  closure  of  the  jaws  is,  how- 
ever, rarely  in  this  part.  An  acute  suppurative  arthritis 
due  to  injury  or  to  extension  of  suppuration  from  the 


72  SURGICAL    DIAGNOSIS. 

ear,  or  the  subacute  and  chronic  forms  of  arthritis  due 
to  tubercle,  gout,  rheumatoid  arthritis,  &c.,  generally 
present  but  little  difficulty  in  diagnosis. 

Closure  of  the  jaws  due  to  the  mechanical  hindrance 
of  the  movements  of  the  lower  jaw  by  large  malignant 
and  other  tumours  of  the  neck,  requires  no  special  men- 
tion. The  closure  of  the  jaws  that  is  one  of  the  earliest 
symptoms  of  tetanus  is  scarcely  likely  to  be  confused 
with  any  of  the  preceding  affections. 

It  is  important  to  remember  that  inability  to  open 
the  mouth  is  not  a  very  uncommon  manifestation  of 
hysteria.  The  age,  sex,  and  manners  of  the  patient, 
together  with  complete  absence  of  any  signs  of  local 
disease,  are  usually  sufficient  to  raise  a  suspicion  as  to 
the  nature  of  the  complaint,  and  a  little  judicious  con- 
versation on  the  part  of  the  surgeon  will  generally 
succeed  in  betraying  the  patient  into  opening  his  (or, 
more  probably,  her)  mouth. 


CHAPTER  VII. 

DISEASES  OF  THE  TONGUE  AND 
FLOOR  OF  THE  MOUTH. 

General  enlargement  of  the  tongue  is  caused  by 
acute  inflammation  (glossitis),  usually  secondary  to  a 
wound  or  to  an  ulcer  of  the  tongue  itself  or  of  a 
neighbouring  part.  Any  inflammatory  swelling  in  the 
neighbourhood  of  the  mouth  may  lead  to  glossitis.  The 
diagnosis  of  an  acute  glossitis  is  made  by  the  presence 
of  the  usual  signs  of  inflammation.  The  recognition  of 
the  cause  is  important,  and  it  is  well  also  in  dealing 
with  any  case  of  glossitis  to  notice  the  condition  of  the 
breathing,  and  to  remember  that  the  inflammation 
may  readily  spread  to  the  larynx  and  set  up  an  acute 
oedema. 

Chronic  enlargement  of  the  tongue  is  seen  occasion- 
ally in  young  children  (macroglossia),  and  is  then  due 
probably  in  the  main  to  lymphatic  obstruction.  The 
surface  of  the  tongue  in  such  cases  is  usually  rough,  and 
may  show  dilated  lymphatics. 

The  slight  amount  of  general  enlargement  of  the 
tongue  which  occurs  in  myxoedema  and  other  diseases, 
and  which  is  only  a  part  of  a  general  swelling  affecting 
many  parts  of  the  body,  need  only  be  mentioned. 

Syphilitic  disease  in  the  form  of  gumma  may  cause 


74  SURGICAL    DIAGNOSIS. 

considerable  enlargement,  which  may  be  general,  but  is 
more  often  localised  to  one  or  other  side.  It  is  usually 
diagnosed  by  the  presence  of  easily  recognised  signs 
of  syphilis  upon  the  surface  of  the  tongue  and  else- 
where. 

A  deceptive  appearance  of  enlargement  of  the  tongue 
may  be  produced  when  the  tongue  is  pushed  upwards 
from  below  by  inflammation  (abscess)  or  tumour 
(dermoid  cyst)  in  the  floor  of  the  mouth.  A  careful 
examination  with  one  finger  on  the  floor  of  the  mouth 
and  another  under  the  chin  will  lead  to  the  detection 
of  the  sublingual  swelling. 

x\n  inflammatory  swelling  on  the  floor  of  the  mouth 
on  one  side  only  may  push  the  tongue  over  towards  the 
sound  side.  Such  a  swelling  is  more  likely  to  be  due 
to  a  salivary  calculus  than  to  anything  else.  A  ranula 
produces  a  similar  efi'ect. 

Diminution  in  the  size  of  the  tongue,  apart  from 
injury,  is  rarely  seen  except  as  the  result  of  paralysis 
of  a  hypoglossal  nerve.  If  this  be  unilateral,  as  it 
usually  is,  the  tongue  is  not  only  greatly  atrophied  on 
the  affected  side,  but  when  protruded  it  deviates  to  the 
same  side.  The  diagnosis  is  that  of  affection  of  the 
hypoglossal. 

Difficulty  in  protruding  the  tongue  is  generally  due 
to  some  affection  of  the  floor  of  the  mouth,  either 
inflammation  or  new  growth.  The  most  common  is 
carcinoma.  Another  cause  of  inability  to  protrude  the 
tongue  is  the  congenital  defect  known  as  tongue-tie  ; 
slight  degrees  of  this  affection  are  common,  but  severe 
degrees  are  distinctly  rare. 

It  need   scarcely  be  said  that  the  condition  of  the 
surfaces  of  the  tongue  as  regards  colour,  moisture,  fur. 


DISEASES    OF   THE    TONGUE.  75 

roughness,  &c.,  affords  valuable  indications  as  to  the 
condition  of  the  general  health. 

Quite  apart  from  these,  however,  are  various  local 
affections  of  the  surface,  which  indicate  local  disease. 

Ulceration  of  the  Tongue. 

Superficial    shallow    ulceration    of    the    tongue    is 
generally  indicative  of  syphilis.     Such  superficial  glos- 
sitis   results   in    loss    of    epithelium,    and   the   tongue 
acquires   a    patchy    glazed  appearance,   which  is  very 
characteristic  of  that  disease.     Shallow   ulcers  of  the 
tongue  occur  also  in  connection  with  dyspeptic  con- 
ditions, and  also  as  the  result  of  irritation  from  bad 
teeth.     In  either  case  the  ulcer  is  usually  well  defined 
and  circular,  and  it  is  also  very  likely  to  be  surrounded 
by  a  well-marked  circle  of  redness.     Such  ulcers  are 
usually  attended  by  a  good  deal   of  pain.     Dyspeptic 
ulcers  are  apt  to  be  multiple,  and  to  occur  on  various 
parts  of  the  cheeks,  lips,  &c.,  as  well  as  on  the  tongue. 
Dental  ulcers  are  found  naturally  at  the  side  of  the 
tongue    in   contact    with   the    ofiending   rough    tooth. 
Occasionally  a  simple  ulcer  caused  by  the  irritation  of 
a  jagged  tooth  becomes  so  large,  and  is  surrounded  by 
so  much  inflammatory  induration,  that  a  suspicion  of 
cancer  may  be  roused,  especially  if  the  ulcer  be  some- 
what chronic  in  its  course.     It  is  generally  easy  to  tell 
by  the  absence  of  characteristic  well-defined  induration 
that  we  are  not  dealing  with  the  more  serious  disease. 
Removal  of  the  offending  tooth,  the  frequent  applica- 
tion of  some  simple  mouth  wash,  and  the  delay  of  a  few 
days,    will   in   a    doubtful    case    settle  the  diagnosis. 
Sometimes  it  is  desirable  to  remove  a  small  piece  for 
microscopic  examination, 


76  SURGICAL    DIAGNOSIS. 

A  single  large  ulcer  of  the  tongue  is  usually  either 
syphilitic,  tuberculous,  or  epitheliomatous.  A  primary 
syphilitic  sore  of  the  tongue  is  a  rare  disease ;  it  occurs 
usually  at  the  tip,  and  if  the  possibility  of  its  being 
syphilitic  does  not  occur  to  the  mind  of  the  observer,  it 
may  very  easily  be  mistaken  for  an  epithelioma  on 
account  of  its  indurated  base.  The  resemblance  to 
epithelioma  is  heightened  by  the  induration  and  en- 
largement of  the  adjacent  lymphatic  glands.  Careful 
attention  to  the  history,  to  the  situation,  and  to  the 
flatness  and  circularity  of  the  ulcer,  and  to  the  age  of 
the  patient,  usually  suffices  for  the  diagnosis. 

Single  tertiary  syphilitic  ulcers  caused  by  the 
breaking  down  of  gummata  usually  are  deeply 
excavated,  have  undermined  edges,  and  present  very 
little  surrounding  induration.  The  presence  of 
other  manifestations  of  syphilis  on  the  tongue  and 
elsewhere  generally  make  the  diagnosis  sufficiently 
obvious. 

Tuberculous  ulcers  occurring,  as  they  usually  do,  in 
persons  who  are  the  subjects  of  well-marked  pulmonary, 
laryngeal  or  facial  tuberculosis,  seldom  present  any 
difficulty  in  diagnosis.  When  a  tuberculous  ulcer 
occurs  in  an  elderly  person  who  is  not  obviously 
tuberculous,  considerable  difficulty  in  diagnosis  may 
arise,  and  such  an  ulcer  is  not  unlikely  to  be  mistaken 
for  epithelioma.  Both  the  primary  ulcer  and  the 
glands,  if  enlarged,  lack  the  characteristic  induration 
of  epithelioma  ;  the  edge  is  apt  to  be  undermined  and 
the  surface  to  secrete  more  pus  than  does  an  epithe- 
lioma. Bacteriological  investigation,  or  microscopic 
examination  of  an  excised  bit  of  the  ulcer,  or  even 
injection  of  some  of  the  secretion  into  a  guinea-pig, 


DISEASES    OF   THE   TONGUE.  77 

may  occasionally  be  necessary  before  the  diagnosis  can 
be  made  with  certainty. 

Epithelioma  is  to  be  diagnosed  by  the  evidence  of 
(i)  local  infiltration,  and  (ii)  involvement  of  neighbour- 
ing glands. 

It  is  scarcely  possible,  however,  to  lay  too  much 
stress  upon  the  fact  that  the  second  of  these  conditions, 
the  involvement  of  glands,  indicates  a  comparatively  late 
stage  of  the  disease.  Unfortunately,  epithelioma  of 
the  tongue  when  first  brought  under  our  notice  has 
only  too  frequently  already  caused  palpable  implication 
of  glands.  Nevertheless,  it  is  in  the  earlier  stage, 
before  the  glands  are  evidently  affected,  that  the 
diagnosis  ought  to  be  made,  if  treatment  is  to  be  really 
eflicacious.  In  the  vast  majority  of  cases  the  diagnosis 
can  be  made,  and  should  be  made,  by  careful  attention 
to  the  local  characters  of  the  primary  affection. 
To  wait  until  glands  are  obviously  affected  before 
making  a  diagnosis  of  epithelioma  of  the  tongue 
often  means  to  inflict  an  irreparable  injury  upon 
the  patient,  and  the  practice  cannot  be  too  strongly 
condemned. 

The  really  important  part  of  the  subject  is  therefore 
the  diagnosis  of  the  early  stage  from  the  local  signs, 
at  the  time  when  treatment  may  reasonably  be  expected 
to  be  of  great  value  to  the  patient. 

The  epitheliomatous  ulcer  is  an  ulcer  on  the  top  of  a 
mass  of  new  growth,  and  it  is  the  existence  of  this 
mass  in  the  tongue  which  gives  the  clue  to  the  diagnosis. 
A  well-defined  hard  base  is  characteristic  of  epithelioma. 
This  hardness  may  be  simulated  by  that  of  a  primary 
syphilitic  sore  (see  above),  and  in  some  rare  cases  by 
inflammation  around  a  syphilitic  or  perhaps    even    a 


78  SURGICAL   DIAGNOSIS. 

simple  ulcer.  The  hardness  of  mere  inflammation  is, 
however,  not  so  definite  as  that  of  epithelioma. 

Microscopic  examination  of  an  excised  portion  is  a 
most  valuable  aid  to  diagnosis,  and  may  afford  the  only- 
certain  means  of  arriving  at  a  correct  conclusion. 
Observation  of  the  effect  of  the  administration  of  iodide 
of  potassium  is  occasionally  useful  m  diagnosis,  but 
only  too  often  this  method  leads  to  loss  of  valuable 
time. 

In  some  cases  of  epithelioma  there  is  much  outward 
overgrowth  of  tissue,  in  the  form  of  a  cauliflower-like 
mass.  Such  cases  are  sometimes  mistaken  on  the  one 
hand  for  simple  papillomata,  on  the  other  hand  for 
syphilitic  or  other  granulomata.  The  presence  of  an 
indurated  base,  or,  if  necessary,  microscopical  examina- 
tion of  a  portion  of  the  tumours,  afford  the  best  means 
of  diagnosis.  It  should  be  remembered  that  in  elderly 
people  simple  papillomata,  especially  if  growing  rapidly, 
are  apt  to  pass  into  a  condition  of  epithelioma.  They 
should  be  viewed,  therefore,  with  much  suspicion,  and 
if  any  doubt  as  to  the  real  nature  exists,  it  is  well  to 
remove  the  growth  and  examine  microscopically. 

The  various  other  innocent  tumours  that  are  found 
upon  the  tongue,  such  as  lymphangiomata,  naevi,  and 
rarely  fibromata,  do  not  present  any  difficulty  in 
diagnosis. 


CHAPTER  VIII. 

DISEASES  OF  THE  PALATE. 

Congenital  affections  of  the  palate  (cleft  palate)  seldom 
present  any  difficulty  in  diagnosis.  Occasionally 
destruction  of  a  portion  of  the  palate  from  injury  or 
from  syphilis  produces  a  condition  resembling  at  first 
sight  a  congenital  cleft.  In  these  non-congenital  cases, 
however,  the  cleft  is  rarely  exactly  in  the  middle  line, 
the  uvula  is  never  divided  into  two  parts,  and  there  is 
always  scarring  at  the  margins  of  the  cleft.  A  con- 
genital cleft  palate  in  which  an  unsuccessful  operation 
has  been  followed  by  scarring  and  loss  of  tissue  from 
sloughing  may  occasionally,  in  the  absence  of  any 
reliable  history,  resemble  a  traumatic  or  syphilitic  cleft 
sufficiently  closely  to  lead  to  error.  Ulceration  of  the 
palate,  if  superficial,  does  not  differ  essentially  from 
that  of  other  parts  of  the  oral  mucous  membrane. 

Deeper  ulceration  may  depend  upon  disease  of  the 
bony  palate,  in  which  case  it  is  likely  to  be  due  to 
tuberculous  or  syphilitic  disease  of  the  bones,  or  to 
necrosis  from  some  other  cause. 

An  inflammatory  swelling  in  the  centre  of  the  palate 
is  more  likely  to  be  due  to  syphilis  than  to  any  other 
cause,  and  has  to  be  diagnosed  by  signs  and  symptoms 
of  syphilis  elsewhere.     Tuberculous  swellings  are  less 


8o  SURGICAL   DIAGNOSIS. 

common,  and  the  diagnosis  is  made  in  a  similar  manner. 
The  condition  of  the  teeth  should  always  be  carefully- 
investigated  in  any  case  of  inflammatory  swelling 
about  the  palate,  especially  if  the  swelling  be  at  the 
margin  of  the  jDalate  near  the  alveolar  border.  A 
swelling  in  the  centre  of  the  palate,  away  from  the 
teeth,  is  much  more  likely  to  be  a  gumma  than  an 
alveolar  abscess.  Alveolar  abscess  is  far  more  common 
on  the  outer  than  on  the  inner  surface  of  the  alveolus. 
In  the  case,  however,  of  the  upper  central  incisors  the 
inflammatory  swelling  caused  by  caries  often  occurs  on 
the  palatine  side  of  the  alveolar  margin.  It  is  not 
uulikely  that  it  will  be  in  the  middle  line,  and  even  at 
a  little  distance  from  the  teeth.  Such  a  swelling  is 
often  mistaken  for  a  gumma,  especially  if  care  be  not 
taken  to  examine  the  posterior  surface  of  the  incisor 
teeth  with  a  dental  mirror. 

Of  innocent  tumours  of  the  palate  there  is  but  one 
that  is  at  all  common,  namely,  the  adenoma,  springing 
from  the  submucous  palatine  glands.  It  is  easily 
diagnosed  by  its  prominence,  definition,  slight  nodu- 
larity, and  by  its  history  of  slow  growth. 

Of  malignant  tumours  by  far  the  commonest  is  the 
epithelioma,  recognised  by  the  ordinary  characters  of 
that  disease.  Sarcomata  occasionally  occur  in  the 
palate.  They  are  likely  to  be  mistaken  for  inflamma- 
tory swellings  such  as  gumma.  Growths,  both  sarco- 
matous and  carcinomatous,  originating  in  the  upper 
jaw  or  elsewhere  away  from  the  palate,  often  extend 
downwards  and  inwards  to  the  palate,  and  cause  local 
bulging,  which  may  be  at  first  sight  mistaken  for 
primary  disease  of  the  palate. 


CHAPTER   IX. 

DYSPHAGIA. 

Difficulty  in  swallowing,  or  dysphagia,  maybe  due  to 
various  causes,  of  which  the  principal  may  be  grouped 
as  follows  : 

Mechanical  obstruction  inside  the  month,  pharynx, 
or  oesophagus,  e.g.y  an  impacted  plate  of  false  teeth. 

Mechanical  pressure  upon  these  parts  from  the  out- 
side, e.g.,  a  tumour  of  the  neck  pressing  upon  the 
pharynx,  an  aneurism  of  the  descending  aorta 
compressing  the  cesophagus. 

Mechanical  obstruction  due  to  disease  in  the  wall  of 
the  pharynx  or  oesophagus,  usually  new  growth  or 
inflammation,  or  the  scarring  resulting  from  the 
latter. 

Nervous  and  muscular  causes,  such  as  paralysis  of 
the  muscles  of  the  pharynx,  spasm  of  muscles  (e.^., 
in  tetanus),  and  hysteria. 

Methods  of  Examination. 

The  examination  of  any  case  of  dysphagia  of  which 
the  cause  is  unknown  should  include  the  following  : 

I.  Examination  of  the  neck  from  the  out- 
side, special  attention  being  paid  to  the  pharynx  and 

F 


82  SURGICAL    DIAGNOSIS. 

oesophagus.  By  rotating  the  larynx  axially,  its  posterior 
surface  can  often  be  examined  fairly  thoroughly.  Deep 
palpation  at  the  root  of  the  neck  just  above  the  sternum 
will  often  reveal  the  existence  of  a  primary  carcinoma 
of  the  oesophagus,  or  of  a  nodule  of  carcinoma  second- 
ary to  a  growth  situated  lower  down. 

2.  Examination  of  the  chest,  both  back  and 
front,  should  be  made  in  the  ordinary  way.  Dysphagia 
may  be  produced  by  pericardial  or  pleural  effusion,  by 
intra-thoracic  growths,  and  by  various  other  diseases,  the 
diagnosis  of  which  usually  concerns  the  physician  rather 
than  the  surgeon.  Auscultation  of  the  back  while  the 
patient  is  drinking  is  sometimes  of  value  in  the  detec- 
tion of  a  stricture  of  the  oesophagus,  the  normal  short 
sound  being  replaced  by  a  rushing,  gurgling  noise  as 
the  liquid  passes  the  stricture. 

It  is  well  to  remember  that  examination  of  the 
front  of  the  chest  does  not  throw  any  light  on  the 
question  of  the  presence  of  aneurism  as  a  cause  of 
dysphagia.  Aneurisms  of  the  first  and  second  parts  of 
the  arch,  which  are  those  most  easily  detected  by  physi- 
cal examination,  are  not  those  that  produce  dysphagia. 
Aneurisms  which  cause  dysphagia  are  those  of  the 
descending  aorta.  These,  if  they  can  be  diagnosed  at 
all  by  physical  examination,  are  to  be  detected  only  by 
examination  of  the  back. 

3.  Examination  of  the  interior  of  the  mouth 
and  pharynx  visually  with  a  good  light.  The  finger 
and  probe  may  also  be  useful  in  examining  these  parts. 
The  lower  parts  of  the  pharynx  and  the  back  of  the 
tongue  and  larynx  should  also  be  carefully  examined 
by  means  of  the  laryngoscope.  Disease  of  the  larynx 
itself  is  a  frequent  cause  of  dysphagia.     This   symp- 


DYSPHAGIA.  83 

torn  is  often  the  earliest  and  most  prominent  feature 
of  some  forms  of  laryngeal  disease,  e.g.,  tuberculous 
laryngitis. 

The  laryngoscope  may  reveal  the  cause  of  dysphagia 
{a)  by  showing  disease  of  the  pharj'nx  itself,  e.g.,  an  epi- 
thelioma at  the  back  of  the  cricoid  or  elsewhere  about 
the  pharynx  ;  {h)  by  showing  disease  of  the  larynx, 
such  as  tuberculous  disease  or  other  inflammatory  con- 
ditions ;  (c)  by  showing  paralysis  of  a  vocal  cord,  which 
may  be  due  to  some  affection  of  the  oesophagus  involv- 
ing one  or  other  recurrent  laryngeal  nerve.  Carcinoma 
of  the  oesophagus  is  the  most  common  cause  of  such 
paralysis  associated  with  dysphagia,  but  occasionally 
inflammatory  affections  such  as  abscess  close  to  the 
oesophagus,  or  even  aneurism,  may  cause  it. 

The  laryngoscope  occasionally  affords  visible  proof  of 
the  presence  of  a  carcinoma  of  the  oesophagus  when  the 
growth  can  be  seen  penetrating  the  trachea. 

4.  Examination  of  the  oesophagus  from 
within  must  be  made  instrumentally  by  bougies,  and 
occasionally  by  the  oesophagoscope. 

CEsophagoscope. — This  instrument  is  not  of  much 
practical  value,  as  it  is  very  difficult  to  insert  a  straight 
tube  into  a  passage  so  curved  as  that  which  is  formed  by 
the  mouth,  pharynx,  and  oesophagus.  Moreover,  the  risk 
of  doing  damage  by  lacerating  surrounding  parts  is 
considerable.  Finally,  even  if  a  good  view  of  the  oeso- 
phagus be  obtained,  it  is  not  always  easy  to  learn  more 
about  the  morbid  condition  than  can  be  learnt  by  much 
simpler  means  of  diagnosis. 

Bougies. — These  may  be  made  of  gum  elastic  web- 
bing, of  catgut,  or  of  other  flexible  materials.  They  are 
used   to  ascertain  the  presence  of  narrowing   of   the 


84  SURGICAL   DIAGNOSIS. 

oesophagus  and  to  a  certain  extent  to  gauge  the  degree 
of  that  narrowing. 

In  passing  a  bougie  the  patient  should  crane  his  head 
forward,  not  extend  it  backwards.  The  entrance  of  the 
bougie  into  the  oesophagus  is  then  facilitated.  The 
point  impinges  at  first  against  the  posterior  wall  of  the 
pharynx,  but  can  be  guided  into  the  right  direction  by 
the  left  forefinger  introduced  into  the  back  of  the 
mouth. 

In  passing  an  oesophageal  bougie  the  greatest  care 
should  be  exercised  lest  the  point  of  the  instrument 
be  passed  through  the  diseased  wall  of  the  oesophagus. 
This  can  easily  be  done  in  a  case  of  carcinoma  or  of 
aneurism. 

The  commencement  of  the  oesophagus,  at  the  lower 
border  of  the  cricoid  cartilage,  is,  in  a  person  of  average 
size,  at  a  distance  of  seven  inches  from  the  front  teeth. 
The  lower  end  is  some  nine  or  ten  inches  lower  down, 
that  is  sixteen  or  seventeen  inches  from  the  teeth. 

An  oesophageal  bougie  is  often  arrested  at  the  level 
of  the  upper  border  of  the  cricoid  some  six  inches  from 
the  teeth,  and  care  should  be  taken  lest  diagnosis  of 
stricture  at  this  point  be  made  upon  insufiicient 
grounds. 

5.  Examination  by  X-rays  is  sometimes  of 
service  in  ascertaining  the  cause  of  dysphagia.  It  is 
chiefly  useful  in  determining  the  situation  of  metallic 
foreign  bodies  in  pharynx  or  oesophagus.  It  is  also 
occasionally  useful  in  the  detection  of  aneurism  of  the 
aorta,  caries  of  the  spine,  &c. 

Important  evidence  of  considerable  oesophageal  stric- 
ture (malignant  or  otherwise)  is  obtained  from  the 
presence  of  glairy  saliva  which  collects  in  the  patient's 


DYSPHAGIA.  85 

mouth  or  hangs  from  his  lips.  The  saliva,  which  nor- 
mally passes  in  considerable  quantity  into  the  stomach, 
is  prevented  by  the  stricture  from  doing  so,  and  conse- 
quently collects  above  the  stricture  and  regurgitates 
into  the  mouth.  Although  most  often  seen  in  cases 
of  malignant  stricture,  it  is  not  pathognomonic  of 
malignancy,  but  only  of  obstruction. 

Blood-stained  expectoration  may  be  seen  in  some 
cases  of  extensive  ulcerative  disease  of  the  pharynx  or 
oesophagus.  It  is  especially  apt  to  occur  after  local 
examination  has  been  made  with  finger  or  bougie. 
Marked  tendency  to  haemorrhage  indicates  a  friable 
surface  of  ulceration  and  often  means  epithelioma. 
But  many,  indeed  most,  cases  of  malignant  disease  of 
the  cesophagiis  show  no  sign  of  blood  unless  irritated 
by  rough  attempts  to  pass  bougies. 

Apart  from  the  various  acute  affections  of  the  mouth, 
throat,  and  neck,  which  usually  present  no  difficulty  in 
diagnosis,  the  commonest  and  most  important  cause  of 
dysphagia  is  malignant  disease  (epithelioma)  of  the 
oesophagus.  When  a  middle-aged  or  elderly  person 
complains  of  dysphagia,  which  has  existed  for  a  few 
weeks  or  months  without  any  other  marked  symptoms, 
the  existence  of  a  carcinomatous  stricture  should  be 
strongly  suspected.  If  the  passage  of  a  bougie  indi- 
cates the  presence  of  an  obstruction,  the  diagnosis 
is  strengthened.  Certain  signs  of  epithelioma  may 
also  be  present.  If  the  growth  be  quite  high  up  in  the 
oesophagus,  it  may  be  felt  as  a  small  hard  mass  behind 
the  trachea.  Or  hard  glands  may  be  felt  in  this 
situation,  indicating  malignant  disease  lower  down. 
Paralysis  of  one  or  other  vocal  cord  is  also  common  in 
connection  with  epithelioma  involving  the  upper  part 


86  SURGICAL   DIAGNOSIS. 

of  the  oesophagus,  that  part,  namely,  which  is  in  con- 
tact with  the  recurrent  laryngeal  nerves. 

Progressive  emaciation  and  weakness  are  also  com- 
mon in  cases  of  carcinoma  of  the  oesophagus.  They 
are,  however,  not  necessarily  present  in  the  earlier 
stages,  and  are  not  essential  for  the  diagnosis.  In- 
deed a  man  with  carcinoma  of  the  oesophagus  may  at 
first  appear  to  be  in  robust  health.  Emaciation  and 
weakness  may  be  present,  on  the  other  hand,  in  cases 
of  innocent  stricture.  In  this  case  they  are  due  to 
starvation  from  the  mechanical  hindrance  to  the  passage 
of  food  into  the  stomach. 

Innocent  stricture  of  the  oesophagus  can  scarcely  be 
diagnosed  in  the  absence  of  a  history  of  injury  (usually 
the  swallowing  of  some  corrosive),  or  a  history  that  the 
dysphagia  has  existed  for  a  very  long  time.  It  may  be 
suspected  in  cases  in  which  the  general  nutrition  of 
the  body  is  better  than  the  duration  of  the  symptoms 
would  warrant  on  the  supposition  that  the  disease  was 
malignant. 

A  congenital  pouch  of  the  pharynx  or  oesophagus  may 
be  diagnosed  by  two  symptoms  commonly  present. 
The  patient  vomits  or  regurgitates  undigested  food  that 
be  has  swallowed  some  little  time,  perhaps  some  days, 
before.  The  passage  of  a  bougie  into  the  stomach  is 
sometimes  impossible,  sometimes  quite  easy,  according 
as  the  point  of  the  bougie  enters  the  pouch  or  remains 
in  the  oesophagus.  Sometimes  the  patient  can  himself 
empty  the  pouch  when  it  is  in  the  neck  by  pressing 
upon  it  with  his  fingers. 

The  history  of  the  symptoms  in  a  case  of  congenital 
pouch  of  the  oesophagus  generally  extends  over  many 
years. 


DYSPHAGIA.  87 

The  very  rare  innocent  tumours  of  the  pharynx 
and  oesophagus  can  seldom  be  diagnosed  with  certainty 
unless  they  can  be  seen  or  felt  with  laryngoscope  or 
finger. 

Of  the  various  causes  of  dysphagia  associated  with 
diseases  of  the  nervous  and  muscular  system  but  little 
need  be  said.  Such  diseases  as  tetanus  and  hydro- 
phobia are  easily  recognised  by  symptoms  other  than 
the  dysphagia.  Paralytic  affections  are  recognised  by 
the  history,  as  in  diphtheritic  paralysis,  or  by  the  pre- 
sence of  other  symptoms  of  disease  of  the  nervous 
system,  as  in  glosso-labio-laryngeal  paralysis. 

An  important  cause  of  dysphagia  which  must  be 
mentioned  here  is  hysteria.  Trouble  in  swallowing 
is  one  of  the  ordinary  manifestations  of  this  Protean 
disease.  In  a  young  person  it  is  likely  to  be  mistaken 
for  the  beginning  of  some  such  disease  as  tuberculous 
laryngitis.  In  an  elderly  person  it  may  be  extremely 
difficult  to  diagnose  from  carcinoma  of  the  oesophagus. 
It  is,  of  course,  much  more  common  in  women  than  in 
men.  The  character  of  the  patient,  the  presence  of 
other  symptoms  of  hysteria,  and  the  negative  evidence 
of  disease  obtained  by  the  passage  of  a  full-sized  bougie 
into  the  stomach,  are  usually  sufficient  for  the  diagnosis. 


CHAPTER   X. 

DISEASES    OF    THE    LARYNX. 

History. — The  larynx  is  an  organ  that  serves  the 
twofold  function  of  producing  voice  and  transmitting 
air  to  the  lungs.  From  the  close  connection  of  the 
larynx  with  the  pharynx,  laryngeal  diseases,  and  espe- 
cially those  of  an  inflammatory  nature,  are  likely  to 
interfere  more  or  less  with  the  satisfactory  performance 
of  the  act  of  deglutition.  It  is  obvious,  therefore,  that 
in  ascertaining  the  history  of  a  case  of  supposed  disease 
of  the  larynx  special  attention  should  be  directed  to 
the  manner  in  which  these  three  functions  of  phonation, 
respiration,  and  deglutition  have  been  performed. 

Disease  of  the  larynx  may  be  purely  local,  or,  on  the 
other  hand,  it  may  be  but  a  local  sign  of  some  general 
disease,  such  as  tuberculosis,  renal  disease,  or  some 
specific  fever. 

Tuberculous  laryngitis  occurring  as  a  complication 
of  pulmonary  phthisis,  oedema  of  the  larynx  due  to 
Bright's  disease,  and  laryngitis  in  the  course  of  typhoid 
fever,  may  be  cited  as  examples. 

The  laryngeal  affection  may  also  be  but  a  local  mani- 
festation of  a  disease  affecting  some  more  or  less  distant 
part  directly  connected  with  the  larynx  by  means  of  one 
or  other  of  the  laryngeal  nerves. 


DISEASES    OF   THE    LARYNX.  89 

Thus,  superior  laryngeal  paralysis  may  be  a  sign 
of  that  disease  of  the  medulla  known  as  glosso-labio- 
laryngeal  palsy,  or  paralysis  of  a  vocal  cord  may  be  the 
laryngeal  sign  of  thoracic  aneurism,  of  carcinoma  of  the 
oesophagus,  or  of  some  other  local  disease  affecting  the 
recurrent  laryngeal  nerve  at  a  distance  from  the  larynx 
itself. 

The  importance  of  directing  attention  to  the  condition 
of  other  parts  of  the  body,  and  especially  to  the  lungs 
and  kidneys,  is  therefore  obvious. 

Symptoms  of  Laryngeal  Disease. 

1.  Phonation. — Anything  which  interferes  with 
the  free  and  natural  movements  of  the  cords,  or  alters 
their  tension,  or  which  causes  roughness  of  their  delicate 
edges,  will  lead  to  alteration  of  the  voice  (dysphonia). 
The  most  common  alteration  is  in  the  direction  of 
hoarseness,  as  seen  in  simple  catarrhal  laryngitis,  or  in 
the  case  of  a  tumour  growing  from  the  cord,  or  when  a 
cord  is  fixed  and  unable  to  move.  A  squeaky,  high- 
pitched  voice  may,  on  the  other  hand,  be  the  result  of 
some  increase  in  the  tension  of  the  cord.  Diminution  of 
the  normal  tension  of  the  cord  leads,  on  the  other  hand, 
to  a  lower  pitch  of  voice,  as  in  the  case  of  paralysis  of 
the  superior  laryngeal  nerve. 

Aphonia,  or  loss  of  voice,  may  result  either  from 
inability  to  move  the  cords,  as  in  severe  forms  of  laryn- 
gitis, or  from  their  destruction  from  ulceration,  or  may 
merely  be  a  manifestation  of  hysteria. 

2.  Respiration. — Anything  which  obstructs  the 
free  flow  of  air  through  the  larynx  naturally  tends  to 
cause  difficulty  in  breathing  (dyspnoea).     The  obstruc- 


90  SURGICAL   DIAGNOSIS. 

tion  may  be  caused  by  swelling  of  some  portion  of 
the  larynx  itself  (as  in  oedema  of  the  larynx,  laryn- 
gitis, gumma,  or  new  growtli)  ;  by  temporary  or  per- 
manent approximation  of  the  vocal  cords  to  one 
another  (spasm  of  the  glottis,  abductor  paralysis)  ;  or 
by  the  presence  of  some  foreign  body  in  the  cavity 
of  the  larynx  (a  foreign  body  introduced  from  with- 
out, such  as  a  piece  of  bone,  or  formed  within  the 
larynx,  such  as  diphtheritic  membrane).  Frequently 
two  or  more  of  these  causes  are  combined,  as  in  the 
case  of  diphtheria,  causing  laryngeal  inflammation 
and  swelling,  and  also  obstructing  the  larynx  with 
membrane  ;  or  when  a  piece  of  bone  in  the  larynx  sets 
up  laryngitis. 

3.  Deglutition. — Any  painful  affection  of  the 
larynx  is  likely  to  cause  difficulty  in  swallowing 
(dysphagia),  because  of  the  painful  movement  of 
the  larynx  thereby  occasioned.  A  swelling  of  the 
posterior  part  of  the  larynx,  such  as  that  produced 
by  necrosis  or  perichondritis  of  the  cricoid  cartilage, 
may  also  cause  dysphagia  by  producing  a  mechanical 
obstruction.  So  also  may  a  malignant  tumour  which 
has  extended  beyond  the  confines  of  the  larynx  itself. 

An  old  aphorism,  dating  from  before  the  days  of  the 
laryngoscope,  says  that  difficulty  of  swallowing  for 
which  no  adequate  cause  is  visible  in  the  fauces,  fol- 
lowed by  difficulty  of  breathing  for  which  no  adequate 
cause  can  be  discovered  in  the  thorax,  indicates  acute 
laryngitis.  *  Painful  deglutition  is  often  one  of  the  most 
prominent  symptoms  of  laryngeal  tuberculosis. 

*  Watson,  "  Principles  and  Practice  of  Physic,"  vol.  i.  pp.  864-5. 


DISEASES    OF   THE   LARYNX.  9 1 

Physical  Examination. 

Examination  of  the  exterior  of  the  larynx  from  the 
neck  occasionally  affords  useful  information,  and  should 
never  be  omitted. 

Various  inflammatory  affections  of  the  larynx,  such 
as  perichondritis  and  necrosis  of  the  cartilages,  may 
cause  a  general  or  local  thickening  of  the  soft  tissues 
outside  the  larynx,  giving  the  impression  that  that 
organ  is  larger  than  it  really  is.  Tumours  of  con- 
siderable size  within  the  larynx  may  cause  an  expan- 
sion of  the  wings  of  the  thyroid  cartilage,  which  can 
easily  be  felt  from  the  outside.  In  its  later  stages 
a  malignant  tumour  may  extend  to  the  exterior  of 
the  larynx  and  be  accessible  to  direct  external  ex- 
amination. Chronic  inflammatory  affections  of  the 
larynx  such  as  tubercle  frequently  extend  to  the 
exterior  of  that  organ,  producing  inflammatory  oedema 
or  abscess  of  the  cellular  tissue  in  the  immediate 
neighbourhood  of  the  larynx.  The  cervical  glands, 
too,  may  be  involved  in  tuberculous  and  other  diseases 
of  the  larynx. 

Examination  of  the  interior  of  the  larynx  is  con- 
ducted almost  entirely  by  means  of  the  laryngoscope. 
Examination  by  the  finger  is  occasionally  useful  in  the 
detection  of  diseases  involving  the  upper  part  of  the 
larynx,  such  as  the  epiglottis,  aryepiglottidean  folds, 
and  arytenoid  cartilages.  The  rare  congenital  malfor- 
mation of  the  epiglottis  and  the  common  inflammatory 
swelling  of  the  aryepiglottidean  fold  may  be  detected 
in  this  way.  In  children  especially  are  these  parts 
easily  accessible  to  the  examining  finger.  The  intro- 
duction of  a  laryngeal  probe  is  sometimes  of  use  in 


92  SURGICAL    DIAGNOSIS. 

determining   the    mobility  or   otherwise  of   an  intra- 
laryngeal  growth. 

Before  proceeding  to  the  examination  of  the  larynx 
itself  with  the  laryngoscope,  it  is  well  to  make  a  care- 
ful and  thorough  inspection  of  the  mouth,  tongue, 
pharynx,  and  neighbouring  parts,  since  disease  in 
these  parts  may  afford  valuable  indications  as  to  the 
nature  of  the  laryngeal  affection.  Thus  the  nature 
of  an  otherwise  obscure  ulceration  of  the  lai'ynx 
may  be  indicated  by  the  presence  of  typical  tuber- 
culous, syphilitic,  or  other  disease  of  the  tongue  or 
pharynx. 

Examination  of  the  fossae  in  the  immediate  neigh- 
bourhood of  the  larynx  (glosso-epiglottic  fossge),  and  of 
the  pharynx  behind  these,  may  reveal  the  presence  of 
some  primary  disease  which  has  extended  to,  and  thus 
caused,  disease  of  the  larynx. 

In  order  to  make  a  proper  laryngoscopic  examina- 
tion, spraying  or  jDainting  of  the  throat  with  cocaine 
may  be  necessary  in  the  case  of  nervous  or  very 
sensitive  patients.  In  the  case  of  young  children, 
the  employment  of  a  general  anaesthetic  is  often 
essential. 

In  examining  the  interior  of  the  larynx,  attention 
should  be  directed  to 

(i)  The  mucous  membrane,  whether  congested, 
ulcerated,  or  scarred. 

(ii)  The  submucous  tissue,  whether  oedematous  or 
the  seat  of  any  other  local  or  general  swelling. 

(iii)  The  vocal  cords,  as  regards  their  position  and 
movements. 

(iv)  The  presence  of  any  structure  within  the  cavity 
of   the    larynx,    either    a    foreign    body,  or  some   out- 


DISEASES    OF   THE    LARYNX.  93 

growth  from  the  larynx  itself — a  tumour,  inuocent  or 
malignant. 

(i)  Mucous  membrane. — Congestion  or  inflam- 
mation of  the  larynx  produces  a  general  vascularity  of 
the  larynx  which  is  best  seen  on  the  true  vocal  cords. 
These  lose  their  normal  pearly  white  colour  and  become 
more  or  less  reddened. 

Hoarseness  of  the  voice  is  the  corresponding  symp- 
tom caused  by  this  alteration  in  the  condition  of  the 
vocal  cord. 

Chronic  inflammation  of  the  larynx  causes  the  usual 
appearances  seen  in  mucous  membranes  which  have 
been  subjected  for  a  long  time  to  irritation  and  inflam- 
mation. The  membrane  becomes  thickened,  roughened, 
altered  in  colour,  and  often  presents  minute  but  dis- 
tinct patches  of  local  overgrowth  of  epithelium.  In 
extreme  cases  prominent  warty  growths  may  be  seen. 
These  changes  are  found  on  both  sides  of  the  larynx, 
and  are  usually  symmetrical.  The  region  of  the  vocal 
cords  is  that  in  which  the  changes  of  simple  chronic 
laryngitis  are  most  marked. 

A  granular  condition  of  the  mucous  membrane  is 
suggestive  of  an  early  stage  of  tuberculous  disease, 
especially  if  numerous  minute  yellow  granules  (tuber- 
cles) can  be  seen.  At  a  somewhat  later  stage  of  the 
same  disease  these  little  granules  have  broken  down 
into  ulcers. 

Shallow  ulcers  are  common  also  in  the  severer  forms 
of  simple  laryngitis,  such  as  that  occurring  in  the  later 
stages  of  various  specific  fevers. 

Scarring. — Minute  superficial  scars  may  be  merely 
the  result  of  shallow  superficial  simple  ulcers. 
Scarring,  the  result  of  healed  tuberculous  ulceration. 


94  SURGICAL    DIAGNOSIS. 

is  not  at  all  common,  since  tuberculous  ulceration 
is  usually  progressive,  and  has  not  much  tendency 
to  heal. 

Extensive  scarring,  especially  when  accompanied  by 
m^ich  destruction  of  the  epiglottis  or  the  other  deeper 
parts  of  the  larynx,  is  highly  suggestive  of  syphilitic 
disease. 

(ii)  Submucous  tissues.  —  The  more  severe 
forms  of  inflammation,  whether  acute  or  chronic,  affect 
the  adjacent  submucous  cellular  tissue  as  well  as  the 
mucous  membrane  itself.  Swelling  of  the  cellular 
tissue  may  also  be  caused  by  simple  (Dedema  due  to 
Bright's  disease.  But  oedema  of  the  larynx  in  the 
vast  majority  of  cases  is  due  to  local  inflammation. 
This  oedema  may  be  caused  by  local  injury,  such  as 
inhaling  steam,  drinking  hot  or  corrosive  liquids ;  by 
spread  of  inflammation  from  suiTounding  parts,  as 
in  the  case  of  oedema  of  the  larynx,  secondary  to  some 
ulcer  of  the  tongue  or  pharynx  ;  by  the  presence  of 
some  ulcer  within  the  larynx  itself.  A  septic  con- 
dition of  any  ulcer,  whether  simple,  tuberculous, 
syphilitic  or  malignant,  is  sufficient  to  cause  surround- 
ing oedema. 

Sometimes  the  oedematous  area  is  visible  when  the 
ulcer  which  is  the  cause  of  it  is  out  of  sight,  being 
hidden  by  the  swelling. 

GEdema  naturally  most  readily  affects  that  part  of  the 
larynx  in  which  the  cellular  tissue  is  most  lax  and 
abundant,  that  is,  the  upper  part,  and  especially  the 
aryepiglottidean  folds.  The  submucous  tissue  of  the 
epiglottis,  of  the  interarytenoid  fold,  and  of  the  false 
cord  are  affected  to  a  lesser  degree.  CEdema  of  the 
larynx   never    extends   below    the    true   vocal    cords, 


DISEASES    OF    THE    LARYNX.  95 

because  the  mucous  membrane  is  firmly  attached  to 
those  structures;  this  attachment  limits  its  downward 
spread.  The  rapidity  with  which  oedema  of  the 
larynx  may  occur,  and  the  suddenness  with  which  it 
may  cause  very  serious  and  even  fatal  dyspnoea,  are 
well  known.  CEdema  of  the  larynx  must  always  be 
regarded  as  a  sign  of  serious  import,  and  one  upon 
which  a  careful  watch  must  be  kept. 

The  swelling  caused  by  oedema  of  the  larynx 
is  often  so  great  that  the  interior  of  the  larynx  is 
largely  or  even  wholly  hidden  from  view.  Especially 
is  the  view  of  the  interior  of  the  larynx  obscured 
when  the  oedema  is  unilateral,  and  when  in  addition 
to  the  oedema  there  is  marked  displacement  of  the 
larynx  as  a  whole  (as  by  a  tumour  in  the  neck). 

A  subacute  or  chronic  swelling  of  any  part  of  the 
larynx  may  indicate  not  merely  superficial  oedema,  but 
the  presence  of  some  more  serious  deeply-seated  disease. 
Thus  a  pyriform  swelling  of  the  arytenoid  and  aryepi- 
glottidean  region  frequently  indicates  tuberculous 
disease  of  those  parts. 

In  every  case  of  inflammation  and  ulceration  of  the 
larynx  an  attempt  should  be  made  to  ascertain  the  cause 
of  the  trouble.  This  must  be  done  not  merely  by 
the  local  characters  of  the  laryngeal  disease,  which 
are  often  not  sufficiently  marked  to  be  pathognomonic, 
but  by  examining  for  evidence  of  disease  elsewhere. 
Tubercle  and  syphilis,  for  instance,  both  of  which  are 
common  causes  of  laryngeal  ulceration,  may  have  to  be 
diagnosed  not  so  much  from  the  characters  of  the 
laryngeal  affection,  as  from  the  history  or  the  presence 
of  more  characteristic  lesions  in  other  parts  of  the 
body. 


96  vSURGICAL   DIAGNOSIS. 

The  examination  of  the  sputum  for  tubercle  bacilli 
affords  important  help  in  the  diagnosis  of  tuberculous 
laryngitis. 

(iii)  The  vocal  cords. — Observation  of  the  vocal 
cords  as  regards  their  position  and  movements 
forms  an  important  part  of  a  laryngoscopic  examina- 
tion. 

Displacement  of  both  cords  together  to  one  or  other 
side  of  the  middle  line  usually  indicates  displacement 
of  the  larynx  as  a  whole  ;  examination  of  the  neck 
from  the  outside  will  confirm  this.  Displacement  of 
both  cords  without  displacement  of  the  larynx  as  a 
whole  may  occur,  to  a  certain  extent,  in  some  rare 
cases,  from  the  pressure  of  a  tumour  upon  the  arytenoid 
cartilages.  Forward  displacement  of  one  arytenoid 
cartilage  and  accompanying  shortening  of  the  corres- 
ponding vocal  cord  is  a  very  common  condition,  and 
indicates  paralysis  of  that  cord.  The  cord  in  such  a 
case  lies  in  the  cadaveric  position,  that  is,  midway 
between  abduction  and  adduction.     It  is  immobile. 

The  movements  of  a  vocal  cord  may  be  restricted  or 
entirely  prevented  by 

(a)  Paralysis  of  its  nerve-supply. 

(h)  Inflammation  affecting  subjacent  tissues,  espe- 
cially the  intrinsic  muscles  and  crico-arytenoid 
joint. 

(c)  Malignant  new  growth. 

(a)  Paralysis  of  the  superior  laryngeal  nerve  is  very 
rare.  Supplj'ing  only  the  cricothyroid  muscle,  this  nerve 
when  paralysed  prevents  the  cord  from  being  stretched 
in  the  utterance  of  high  notes.  The  voice  consequently 
tends  to  be  a  low  bass  one. 

Since  this  nerve  is  also  the  sensory  nerve  to  the 


DISEASES    OF   THE    LARYNX.  97 

mucous  membrane  of  the  larynx,  its  paralysis  is  ac- 
companied by  ana3sthesia  of  the  upper  part  of  the 
larynx.  This  condition  is  detected  either  by  direct 
examination  or  by  the  history  that  particles  of  food 
easily  pass  into  the  larynx  or  beyond  it,  and  set  up 
irritation  in  these  parts. 

Paralysis  of  the  inferior  or  recurrent  laryngeal  nerve 
is  far  more  common.  Being  the  principal  motor  nerve 
to  the  larynx  (supplying  all  the  intrinsic  muscles 
except  the  cricothyroid)  its  paralysis  affects  both 
abductors  and  adductors  of  the  cords.  The  cord  con- 
sequently assumes  the  cadaveric  position,  and  is  im- 
mobile. 

It  is  important  to  remember  that  when  this  nerve  is 
slowly  losing  its  function,  the  abductors  of  the  cord  are 
paralysed  sooner  than  the  adductors.  Consequently 
.  the  cord  at  first  assumes  the  position  of  adduction,  and 
only  subsequently,  when  the  paralysis  is  completed, 
takes  up  the  cadaveric  position.  If  both  recurrent 
nerves  are  partially  paralysed  to  an  equal  extent,  which, 
however,  rarely  happens,  both  cords  lie  in  the  adducted 
position,  i.e.,  close  together.  In  such  a  case  there  is 
great  inspiratory  dyspnoea  with  stridor,  and  the  patient 
is  in  imminent  danger  of  being  suddenly  suffocated. 

As  a  rule,  when  both  recurrent  nerves  are  paralysed, 
one  is  affected  before  the  other.  Consequently,  the 
cord  on  one  side  has  become  completely  paralysed,  and 
has  assumed  the  cadaveric  position  before  the  other 
has  become  adducted.  Sufiicient  space  is  thus  left 
between  the  cords  for  breathing  purposes.  When 
the  second  cord  has  too  in  its  turn  become  completely 
paralysed,  still  more  space  is  given  for  the  passage  of 
air. 


98  SURGICAL    DIAGNOSIS. 

(b  and  c)  The  infiltration  b}^  inflaminatory  pro- 
ducts, or  by  new  growth  in  the  tissues  in  the  im- 
mediate neighbourhood  of  the  cord,  naturally  tends  to 
cause  a  mechanical  fixation  of  the  cord.  The  immobility 
thus  caused  is,  however,  seldom  so  marked  as  in  the  case 
of  genuine  paralysis. 

Fixation  of  the  cricoarytenoid  joint  by  inflammation 
of  any  kind  naturally  has  an  injurious  effect  upon  the 
movement  of  the  cord,  attached  as  it  is  posteriorly  to 
the  arytenoid  cartilage.  The  importance  of  fixation  of 
the  cord  in  the  diagnosis  of  early  malignant  disease 
will  be  discussed  later  (page  102). 

(iv.)  The  obstructions  that  occur  within  the 
cavity  of  the  larynx,  and  which  tend  to  block  it 
up,  are — 

1.  Foreign  bodies. 

2.  Projections  from  the  wall  of  the  larj^nx. 

(a)  Inflammatory  (granulomata). 

(6)  Papillomata,   fibromata,  and   other  innocent 

new  growths. 
(c)  Malignant   new    growths    (carcinoma,    very 
rarely  sarcoma). 
I.  Foreign  bodies. 

Except  in  the  case  of  very  young  children,  the 
diagnosis  of  a  foreign  body  is  generally  easily  made. 
The  history  of  a  very  sudden  onset  of  violent  paroxysmal 
dyspnoea,  followed  by  more  or  less  constant  dysphonia 
and  dyspnoea,  and  the  result  of  laryngoscopic  examina- 
tion, are  generally  sufficient  for  a  correct  diagnosis. 
The  definite  history  of  a  foreign  body  having  been  in 
the  mouth  immediately  before  the  onset  of  the  attack 
may  possibly  be  given. 

In  some  cases,  however,  a  characteristic  history  is 


DISEASES    OF   THE    LAHYNX.  99 

wanting  ;  in  others  the  laryngoscopic  examination  may 
fail  to  reveal  the  presence  of  the  foreign  body.  In 
the  case  of  young  children,  a  foreign  body  may  easily 
be  mistaken  for,  or  simulated  by,  laryngeal  diphtheria 
having  an  apparently  sudden  onset,  or  even  by  the 
presence  of  a  papilloma.  The  difficult}^  of  making  a 
thorough  laryngoscopic  examination  in  a  child  adds  to 
the  difficulty  of  diagnosis.  Even  if  a  good  view  of  the 
larynx  be  obtained,  the  presence  of  the  foreign  body 
may  be  overlooked  owing  to  its  small  size,  or  to  its 
being  covered  over  with  mucus  or  hidden  by  inflamma- 
tory swelling.  In  such  cases  the  use  of  a  probe  may 
help  in  detecting  the  presence  of  a  hard  foreign  body. 

Sometimes  tracheotomy  or  thyrotomy  may  become 
necessary  before  the  diagnosis  is  conclusively  estab- 
lished. 

2.  Projections  from  the  wall  of  the  larynx. 

(«)  Granulomata  occur  either  in  the  course  of  some 
specific  disease  such  as  sy23hilis,  or  they  are  due  to 
some  deep-seated  source  of  irritation  such  as  necrosis  of 
cartilage  or  a  foreign  body  embedded  in  the  tissues. 
They  may  be  very  difficult  to  distinguish,  except  by 
the  history,  from  some  new  growths.  The  presence  of 
much  suppuration  would  indicate  the  presence  of  dead 
bone  or  other  foreign  body. 

(h)  Papillomata,  fibromata,  and  other  innocent  new 
growths,  have  to  be  distinguished  on  the  one  hand 
from  inflammatory  swellings,  on  the  other  from 
malignant  new  growths. 

Innocent  new  growths  such  as  fibromata  often  have 
a  polypoid  shape  ;  any  pendulous  mass  with  a  narrow 
pedicle  is  likely  to  be  an  innocent  new  growth. 

Papillomata,  when  they  assume  a  villous  appearance, 


100  SUKGICAL   DIAGNOSIS. 

as  they  often  do,  are  not  difficult  to  recognise. 
Papillomata  are  not  uncommon  in  young  children  at 
an  age  when  malignant  disease  is  practically  unknown. 
Papillomata  are  frequently  multiple  and  occur  on  both 
sides  of  the  larynx ;  this  is  uncommon  with  malignant 
disease. 

(c)  Malignant  disease  when  taking  the  form  of 
a  sarcoma,  which  is  very  rare,  appears  as  a  rounded 
lump  beneath  the  mucous  membrane.  This  gradually 
increases  in  size,  displacing  surrounding  parts  and 
causing  more  and  more  dysphonia  and  dyspnoea. 
At  first  it  is  not  ulcerated,  and  is  most  likely  to 
be  mistaken  for  a  gumma  or  some  other  inflammatory 
swelling. 

The  only  common  form  of  malignant  disease  of  the 
larynx  is  the  squamous  carcinoma  (epithelioma).  The 
symptoms  of  this  disease  vary  considerably  according 
to  the  situation  in  which  the  disease  is  found. 

Extrinsic  carcinoma  is  very  commonly  seen  at  the 
margin  of  the  upper  opening  of  the  larynx,  spreading 
thence  into  the  larynx  itself.  This  disease  appears  as 
a  well-defined,  raised,  ulcerated  mass,  with  a  flattened 
or  roughly  granular  surface. 

The  situation  of  the  ulcer  in  the  pharynx  naturally 
causes  pharyngeal  symptoms  (i.e.,  painful  deglutition), 
rather  than  laryngeal  ones.  The  action  of  the  vocal 
cords  is  often  unimpaired  in  the  earlier  stages  of 
extrinsic  carcinoma.  Frequently,  however,  a  malignant 
ulcer  near  the  larynx  exists  for  a  considerable  time 
without  causing  any  marked  symptoms,  and  the  occur- 
rence of  laryngeal  symptoms  (difficulty  in  breathing) 
may  first  draw  the  patient's  attention  to  his  condition 
and  lead  him  to  seek  advice. 


DISEASES    OF    THE    LARYNX.  lOI 

The  later  stages  of  this  disease  are  not  difficult  to 
diagnose,  and  are  likely  to  be  confounded  only  with 
the  later  stages  of  tuberculous  or  syphilitic  ulceration 
occurring  in  middle-aged  or  elderly  subjects. 

Intrinsic  carcinoma  of  the  larynx  in  its  earlier 
stages  is  frequently  overlooked.  This  is  a  serious  mis- 
take, because  in  its  earlier  stages  this  form  of  cancer  is 
very  amenable  to  radical  treatment,  much  more  so  than 
is  the  extrinsic  carcinoma  situated  in  the  loose  cellular 
tissue  of  the  upper  part  of  the  larynx  or  pharynx. 

Intrinsic  carcinoma  generally  begins  in  the  form  of 
a  small  warty  growth  on  one  true  vocal  cord  or  at  the 
junction  of  the  cords  in  front.  At  this  stage  it  pro- 
duces no  symptom  other  than  hoarseness,  and  is 
generally  attributed  by  the  patient,  and  sometimes  by 
his  medical  attendant,  to  '^a  cold." 

A  persistent  hoarseness,  occurring  in  a 
patient  over  forty  years  of  age,  and  for  -which 
no  cause  is  known,  should  invariably  lead  to 
a  suspicion  of  malignant  disease,  and  a  careful 
laryngoscopic  examination  should  at  once  be  made. 
The  patient's  general  health  may  be  exceedingly  good, 
and  this  very  fact  is  apt  to  deceive  and  to  lead  to  the 
idea  that  "there  cannot  be  cancer."  Much  valuable 
time  may  thus  be  lost  before  the  establishment  of  a 
certain  diagnosis.  Early  diagnosis  is  all  important 
in  the  successful  treatment  of  intra-laryngeal  cancer, 
a  form  of  cancer  the  treatment  of  which,  it  may  be 
remarked,  is  by  no  means  unsuccessful,  if  only  it  is 
undertaken  early,  and  carried  out  efficiently  and 
thoroughly. 

A  laryngoscopic  examination  at  this  early  stage  will 
probably  reveal  a  warty  growth  in  one  or  other  of  the 


102  SURGICAL    DIAGNOSIS. 

above-mentioned  situations,  and  the  question  then 
arises,  "  Is  this  innocent  or  malignant  ? "  a  question 
at  first  often  very  difficult  to  answer. 

One  of  the  most  important  points  in  the  diagnosis  at 
this  stage  is  the  mobility  of  the  vocal  cord  on  which 
the  growth  is  situated.  The  malignant  growth 
infiltrates  the  underlying  tissues,  and  conse- 
quently leads  to  more  or  less  fixity  of  the  cord. 
Innocent  growths  have  no  such  tendency. 

In  doubtful  cases  it  may  be  desirable  to  attempt 
removal  of  a  portion  of  the  growth  with  endolaryngeal 
forceps  or  guillotine,  in  order  to  submit  it  to  micro- 
scopic examination.  It  is  not  always  possible  even 
then,  however,  to  pronounce  with  certainty  as  to  the 
non-malignancy  of  a  laryngeal  new  growth.  If  reason- 
able doubt  still  exists  as  to  the  diagnosis,  thyrotomy 
may  be  performed. 

In  the  later  stages  of  malignant  disease  there  is  less 
difficulty  in  the  diagnosis ;  the  steady  progress  of  the 
disease,  the  presence  of  a  definite  mass  of  growth,  its 
tendency  to  ulcerate  and  perhaps  to  bleed,  later  still 
the  affection  of  lymphatic  glands  and  extension  of  the 
tumour  beyond  the  larynx,  all  serve  to  render  diagnosis 
easy. 

Trachea. 

A  laryngoscopic  examination  may  also  be  required 
for  the  examination  of  the  trachea. 

Under  favourable  conditions,  the  whole  of  the  trachea 
as  far  as  the  bifurcation  can  be  inspected.  Displace- 
ment of  the  trachea,  narrowing  of  its  calibre  by  pres- 
sure from  without  or  by  contraction  of  scars  from 
within,  ulceration  and  new  growths  of  various  kinds. 


DISEASES    OF    THE    LARYNX.  103 

may  have  to  be  investigated  by  the  laryngoscope. 
Another  method  of  examining  the  interior  of  the 
trachea  consists  in  passing  a  straight  tube  through 
the  larynx  while  the  patient  is  under  the  influence  of 
an  anaesthetic.  It  is  said  that  a  good  view  of  the 
trachea  and  even  of  the  bronchi  can  thus  be  obtained. 
The  mechanical  difficulty  and  the  danger  of  passing 
such  a  tube  render  this  method,  however,  one  of  very 
limited  applicability. 


CHAPTER    XI. 

DISEASES  OF  THE  THYROID  GLAND. 

For  purposes  of  diagnosis  diseases  of  the  thyroid  gland 
may  be  conveniently  divided  into  two  classes  : 

1.  Those  which  cause  diminution  in  the  size  of  the 
gland  (atrophy). 

2.  Those  which  cause  enlargement. 

I.  Diseases  causing  diminution  in  the  size 
of  the  gland. 

The  diagnosis  here  depends  almost  wholly  upon  the 
presence  of  general  signs  and  symptoms  of  loss  of 
function  of  the  gland.  The  physical  examination  of 
the  gland  is  of  very  little  importance,  since  it  is  very 
difficult  or  impossible  to  say  definitely  from  mere 
physical  examination  of  the  neck  that  the  gland  is 
absent  or  even  much  diminished  in  size.  The  two 
diseases  characterised  by  loss  of  function  of  the  gland 
are  myxoedema  and  cretinism,  both  of  which  are 
produced  by  atrophy  of  its  secreting  elements. 

The  symptoms  of  both  may  be  summed  up  briefly  as 
follows  : 

Diminution  in  activity,  both  bodily  and  mental.  Dull, 
heavy,  facial  expression,  with  sallow  complexion,  and 
often  a  pink  flush  on  the  cheeks. 

Dryness  and  roughness  of  skin,  and  tendency  to  loss 
of  hair. 


DISEASES    OF    THE    THYROID    GLAND.  105 

Low  temperature. 

In  many  cases  swelling  of  subcutaneous  tissue, 
without  true  oedema. 

In  the  case  of  cretinism,  which  is  practically  myx- 
cedema  occurring  in  early  life,  there  is  also  marked 
arrest  in  the  development  both  of  body  and  mind. 

In  many  cases  of  cretinism,  and  in  a  few  cases  of 
myxoedema,  there  is  no  diminution  in  the  total  size  of 
the  gland.  This  may  even  be  enlarged,  but  in  all  cases 
there  is  atrophy  of  the  glandular  elements.  Myxcedema 
is  most  likely  to  be  mistaken  for  chronic  renal  disease, 
or  for  mere  obesity. 

Cretinism  in  its  well-marked  form  seldom  presents 
any  difficulty  in  diagnosis,  but  may  be  mistaken  for 
rickets  and  for  some  forms  of  idiocy.  The  diagnosis 
has  to  be  made  by  attention  to  the  characters  mentioned 
above. 

2.  Diseases  causing  enlargement  of  the 
thyroid  gland. 

These  are — 

(1)  Simple  goitre  (of  various  kinds). 

(2)  Graves's  disease. 

(3)  Inflammation. 

(4)  Malignant  disease. 

The  two  last  are  comparatively  rare. 

Any  form  of  enlargement  of  the  thyroid  may  be 
accompanied  by  slight  signs  of  loss  of  function  of  the 
gland,  such  as  pallor  and  mental  hebetude  ;  but  as  a  rule 
such  signs  are  not  prominent,  and  are  of  but  little  value 
in  diagnosis.  It  is  remarkable  that  in  some  cases  of 
simple  goitre  the  gland  may  be  so  diseased  as  to  pre- 
serve no  visible  trace  of  its  normal  structure,  and  yet 
be  quite  capable  of  carrying  on  its  normal  work. 


I06  SURGICAL    DIAGNOSIS. 

Diagnosis  of  a  Thyroid  Swelling  from  other 
Swellings  in  the  Neck. 

There  is  usually  but  little  difficulty  in  making  the 
diagnosis.  The  situation  of  the  swelling  in  the  region 
of  the  thyroid  and  the  fact  that  it  moves  up  and  down 
during  the  act  of  deglutition,  are  in  almost  all  cases 
sufficient  to  prove  its  thyroid  nature.  There  are,  how- 
ever, cases  in  which  difficulties  may  arise. 

These  are : 

(i)  Cases  in  which  a  thyroid  tumour  does  not  occupy 
the  normal  situation  of  the  thyroid. 

Masses  of  thyroid  tissue  sometimes  occur  in  outlying 
regions.  These  may  be  tumours  of  an  accessory  thyroid, 
or  more  often  adenomata,  which  have  been  extruded 
from  the  gland  and  are  attached  to  it  by  a  more  or  less 
slender  pedicle.  In  proportion  as  the  tumour  is  more 
or  less  detached  from  the  main  gland,  so  does  it  tend 
to  lose  its  characteristic  sign  of  moving  with  the  larynx 
on  deglutition. 

(2)  Cases  in  which  a  thyroid  tumour,  occupying 
the  situation  of  the  gland,  does  not  move  during 
deglutition. 

These  are  almost  entirely  cases  in  which  the  tumour 
has  been  fixed  by  inflammation  or  by  infiltration  of  new 
growth  to  neighbouring  fixed  structures,  such  as  the 
vertebrae,  sternum,  or  sterno-mastoid  muscles.  In  these 
cases  the  diagnosis  has  to  be  made  partly  by  the  shape 
and  situation  of  the  tumour,  and  partly  by  the  special 
signs  of  inflammation  or  malignancy.  Rarely  simple 
thyroid  tumours,  not  the  seat  of  inflammation,  are 
mechanically  fixed  and  prevented  from  movement  by 
being    jammed  in  the   upper  opening  of  the  thorax. 


DISEASES    OF    THE    THYROID    GLAND.  107 

Such  cases  are  usually,  however,  easily  diagnosed  by  the 
history  and  by  the  severe  dyspnoea  to  which  they  give 
rise.  Sometimes  it  is  difficult  to  distinguish  such  a 
tumour  from  an  aneurism  of  the  aorta. 

(3)  Swellings  not  of  thyroidal  origin  may  occupy  the 
situation  of  the  gland  itself,  and  thus  come  to  simulate 
thyroidal  swellings. 

These  are  chiefly  small  deep-seated  swellings,  springing 
from  lymphatic  glands,  which  have  become  secondarily 
adherent  to  the  trachea  and  larynx.  Dermoid  tumours 
and  other  innocent  new  growths  may  also  occasionally 
become  adherent  in  the  same  manner,  and  thus  follow 
the  movements  of  the  larynx  and  trachea.  Chronic 
abscess  and  other  inflammatory  swellings  originating  in 
disease  of  the  larynx  (perichondritis  and  necrosis)  may 
very  closely  resemble  a  thyroid  swelling.  Examination 
of  the  interior  of  the  larynx  will  often  afford  material 
help  in  the  diagnosis. 

A  malignant  growth  springing  from  the  lower  end  of 
the  pharynx  or  upper  end  of  the  cjesophagus  often  forms 
a  tumour  of  considerable  size,  which  may  present  much 
resemblance  to  a  thyroid  swelling.  When  small  and 
lying  behind  the  thyroid  lobe,  it  may  push  the  latter 
forwards  and  so  cause  it  to  be  unduly  visible  and  pal- 
pable, as  if  it  were  itself  enlarged.  A  larger  mass 
may  displace  the  lobe  and  come  forward  in  its  place 
between  the  sterno-mastoid  muscle  and  the  larynx  or 
trachea. 

Such  growths  may  generally  be  distinguished — 

(i)  By  the  fact  that  the  larynx  and  trachea  can  be  dis- 
placed laterally  away  from  the  tumour,  so  that  a  finger 
may  be  laid  between  these  structures.  This  can  only 
very  rarely  be  done  in  the  case  of  a  thyroid  tumour 


I08  SURGICAL    DIAGNOSIS. 

which  is  lirmly  attached  by  its  ligament  to  the  lower 
part  of  the  larynx. 

(ii)  By  observing  the  relation  of  the  carotid  artery  to 
the  swelling.  Simple  thyroid  tumours  tend  to  displace 
the  artery  outwards,  or  outwards  and  backwards. 
Malignant  thyroid  growths  tend  to  envelop  it  or  to  lie 
in  front  of  it.  Malignant  pharyngeal  or  oesophageal 
growths  often  displace  the  artery  forwards  or  forwards 
and  inwards.  The  situation  of  the  carotid  artery  there- 
fore in  front  of,  or  on  the  inner  side  of,  a  growth, 
affords  a  very  strong  presumption  that  the  latter  is 
not  of  thyroidal  origin. 

Large  masses  of  new  growth,  originating  in  lymphatic 
glands  and  elsewhere,  occasionall}^  cover  up  and  sur- 
round the  whole  of  the  larynx  and  trachea  in  such  a 
manner  as  to  make  it  difficult  to  say  whether  the  thyroid 
is  involved  or  not.  The  early  history  of  such  a  tumour, 
its  irregularity,  the  fact  that  it  spreads  far  beyond  the 
usual  limits  of  a  thyroid  swelling,  and  does  not  preserve 
either  the  shaj)e  or  the  exact  situation  of  a  thyroid 
tumour,  will,  however,  generally  obviate  any  mistake 
in  diagnosis. 


Differential  Diagnosis  of  a  Thyroid  Swelling. 

A  swelling  which  involves  uniformly  the 
-whole  thyroid  gland  presents  usually  but  little 
difficulty  in  diagnosis.  It  is  either  a  parenchymatous 
goitre,  or  it  is  the  goitre  of  Graves's  disease,  or,  rarely, 
if  acute  and  recent,  it  may  be  simply  an  inflamed  thyroid 
gland. 

Acute  inflammation  involving  the  whole  gland  is 
easily  diagnosed  by  the  ordinary  signs  of  inflammation. 


DISEASES    OF   THE   THYROID   GLAND.         109 

The  only  other  condition  which  is  likely  to  be  mistaken 
for  it  is  the  acute  parenchymatous  goitre  of  young 
people.  This  sometimes  enlarges  very  rapidly,  and  has 
often  been  mistaken  for  inflammation.  The  absence  of 
severe  pain  and  of  elevation  of  temperature  are  impor- 
tant points  in  the  diagnosis  of  acute  non-inflammatory 
goitre.  Inflammation  of  the  thyroid,  too,  is  rarely  seen, 
except  as  the  result  of  injury  or  during  convalescence 
from  some  specific  fever,  especially  typhoid. 

The  disease  known  as  chronic  primary  inflammation 
of  the  thyroid,  in  which  the  whole  gland  becomes  slowly 
converted  into  a  mass  of  very  dense  fibrous  tissue,  is  so 
rare  as  not  to  require  further  consideration. 

The  diagnosis  of  the  goitre  of  Graves's  disease  in 
its  well-marked  form  presents  no  difficulty  whatever. 
The  diagnosis  is  made,  however,  not  so  much  by  the 
examination  of  the  gland  itself,  as  by  the  presence  of 
other  characteristic  signs  of  the  disease,  exophthalmos, 
rapidity  of  pulse,  tremulousness,  and  excitability.  The 
gland  itself  is  usually  somewhat  smoother  than  that  of 
a  parenchymatous  goitre.  Marked  pulsation  of  the 
thyroid  vessels  is  often  seen  in  Graves's  disease,  but 
is  in  itself  a  somewhat  fallacious  sign,  and  is  not  to 
be  relied  upon. 

It  is  well  to  remember  that  the  enlargement  of  the 
thyroid  of  Graves's  disease  is  always  uniform  and  sym- 
metrical. The  only  apparent  exceptions  to  this  rule  are 
afforded  by  those  cases  in  which  the  symptoms  of 
Graves's  disease  supervene  in  persons  who  are  already 
the  subjects  of  a  unilateral  (cystic  or  adenomatous) 
goitre.  It  is  important  to  remember,  too,  that  a  some- 
what rapid  pulse  is  not  uncommon  in  persons  who  are 
the  subjects  of  simple  goitre.     Mere  rapidity  of  pulse 


no  SURGICAL    DIAGNOSIS. 

(unless  very  marked  and  persistent),  and  the  presence 
of  a  goitre,  are  nob  in  themselves  sufficient  for  the 
diagnosis  of  Graves's  disease.  It  is  not  uncommon, 
however,  for  the  diagnosis  of  Graves's  disease  to  be 
erroneously  made  on  these  grounds  alone. 

Eeal  difficulty  in  the  diagnosis  of  Graves's  disease 
occurs  only  in  those  early  cases  in  which  the  general 
symptoms  of  the  disease  are  ill-marked,  and  especially 
in  those  cases  in  which  exophthalmos  has  not  yet 
become  apparent.  The  diagnosis  in  such  cases  bas  to 
be  made  partly  by  the  characters  of  the  pulse,  but 
mainly  by  the  nervous,  fidgety  manner  of  the  patient, 
and  her  tremulousness  and  excitability.  The  lessened 
electrical  sensibility  of  the  skin  and  the  presence  of  the 
lid  signs,  described  by  von  Graefe  and  Stellwag,  may 
perhaps  help  in  the  diagnosis,  but  are  not,  in  my 
opinion,  of  much  importance. 

The  later  stages  of  a  parenchymatous  goitre  frequently 
show  other  characters  due  to  the  occurrence  of  small 
cysts  or  adenomata  in  the  gland,  or  to  the  existence  of 
much  fibroid  or  calcareous  degeneration.  The  latter 
may  cause  the  tumour  to  be  extremely  hard,  and  may, 
in  the  absence  of  a  reliable  history,  raise  a  suspicion 
of  malignant  disease. 

A  malignant  tumour,  however,  which  has  progressed 
so  far  as  to  involve  both  lobes  of  the  gland  is  almost 
certain  to  be  fixed  to  surrounding  parts,  and  is  thus 
easily  distinguished  from  the  hard  fibroid  or  calcareous 
goitre  which  has  no  tendency  to  be  so  fixed. 

A  thyroid  swelling  which,  is  limited  strictly 
to  one  lobe  of  the  gland  is  also,  as  a  rule,  not 
difficult  to  diagnose.  With  the  exception  of  inflam- 
mation   and    malignant  disease,    both    of   which    are 


DISEASES    OF   THE    THYROID    GLAND.         Ill 

uncommon  and  usually  have  special  characters  of  their 
own,  a  swelling  involving  only  one  lobe  of  the  thyroid 
is  an  encapsuled  tumour ;  either  an  adenoma  or  a  cyst. 

Such  tumours,  moreover,  are  almost  always  either 
oval  or  globular,  and  never  preserve  exactly  the  natural 
pyriform  shape  of  the  lobe.  Multiple  tumours  in  one 
lobe  present  naturally  an  irregular  lobulated  appear- 
ance. 

The  differential  diagnosis  between  cysts  and  solid 
adenomata  is  frequently  very  difficult.  Adenomata  may 
be  so  soft  as  to  give  rise  to  an  apparent  feeling  of  fluid, 
and,  on  the  other  hand,  cysts  tensely  filled  with  fluid 
and  old  cysts  with  thick,  tough,  fibrous  or  even  cal- 
careous walls,  may  be  extremely  hard.  Many  thyroid 
tumours  are  adenomata  which  have  partly  broken  down 
and  become  cystic  in  the  centre. 

A  very  sudden  and  rapid  enlargement  of  an  encap- 
suled thyroid  tumour  generally  indicates  that  it  is  a 
cyst ;  increased  secretion  or  hasmorrhage  into  its 
interior  causes  the  sudden  enlargement. 

Thyroid  tumours  are  often  present  in  the  middle  line 
of  the  neck,  and  appear  to  spring  from  the  isthmus. 
Occasionally  they  do  really  come  from  this  part  of  the 
gland.  Much  more  often,  however,  a  tumour  in  the 
middle  line  of  the  neck  will  be  found  to  belong  to  the 
lower  part  of  one  or  other  lateral  lobe,  the  trachea  being 
displaced  towards  the  opposite  side.  A  large  prominent 
median  tumour  of  this  kind  occasionally  simulates  a 
general  enlargement  of  the  whole  gland.  A  careful 
examination  of  the  situation  of  the  larynx  and  trachea 
will  show  that  these  are  displaced  to  one  or  other  side 
in  the  case  of  a  tumour.  Such  displacement  never 
occurs  when   the  whole  gland  is  uniformly  enlarged. 


112  SURGICAL   DIAGNOSIS. 

The  tumour,  moreover,  has  a  convex  upper  border  ;  the 
uniformly  enlarged  gland  has  an  upper  border  which  is 
concave,  or  in  which  a  central  notch  (or,  if  a  middle  lobe 
be  present,  two  notches)  can  be  felt. 

Thyroid  swellings  which  involve  both  lobes  of  the 
gland  sometimes  present  difficulties  in  diagnosis. 
Encapsuled  tumours  of  exactly  equal  size,  occurring 
in  both  lobes,  may  be  difficult  to  distinguish  from  a 
general  enlargement  of  the  whole  gland.  Careful 
attention  to  the  shape  of  the  tumours  will,  however, 
generally  show  that  they  are  round  or  oval,  and  do 
not  preserve  exactly  the  shape  of  the  normal  lobe. 
Tumours,  too,  if  bilateral,  are  rarely  of  equal  size,  and 
more  than  two  are  usually  present.  Multiple  encapsuled 
tumours  of  considerable  size  present  no  difficulty  in 
diagnosis.  Many  thyroid  tumours  are,  however,  asso- 
ciated with  more  or  less  general  parenchj^matous  en- 
largement, and  in  such  a  case  the  tumour  or  tumours, 
if  deeply  embedded  in  a  considerable  mass  of  paren- 
chymatous goitre  tissue,  may  escape  detection. 

Conversely  it  occasionally  happens  that  a  strictly 
parenchymatous  goitre  presents  a  lobulated  appearance 
which  can  easily  be  mistaken  for  that  of  multiple  ade- 
nomata or  multiple  cystic  disease. 

Marked  inequality  in  the  size  of  a  bilateral  goitre  is 
almost  pathognomonic  of  the  presence  of  a  tumour  in 
the  larger  lobe. 

Malignant  disease  of  the  thyroid  gland  in  a  well- 
marked  form  seldom  presents  much  difficulty  in  diag- 
nosis. If  the  capsule  of  the  gland  has  been  penetrated 
by  the  growth,  the  latter  becomes  adherent  to  surround- 
ing structures  ;  this  is  shown  partly  by  the  fixity  of  the 
tumour    and   partly   by  involvement  of    neighbouring 


DISEASES    OF    THE    THYROID    GLAND.  II3 

nerves,  especially  the    recurrent    laryngeal,  the    sym- 
pathetic and  those  of  the  cervical  and  brachial  plexuses. 

Paralysis  of  either  of  the  two  former  and  severe  pain 
in  the  area  of  distribution  of  any  of  the  latter  are  rarely 
caused  by  innocent  goitre,  and  should  always  raise  a 
strong  suspicion  of  the  existence  of  malignant  disease 
(or  occasionally  of  inflammation). 

It  is  in  the  earlier  stage  of  the  disease,  before  the 
capsule  of  the  gland  has  been  penetrated,  that  the  diag- 
nosis of  malignant  disease  is  so  difficult.  Indeed,  a 
certain  and  positive  diagnosis  at  this  stage  is  generally 
almost  impossible. 

When,  however,  in  the  gland  of  a  person 
over  forty,  a  tumour  appears  which  is  hard, 
which  steadily  and  rapidly  increases  in  size, 
and  which  is  not  of  an  inflammatory  nature, 
the  malignancy  of  such  a  tumour  should  be 
strongly  suspected. 

If,  moreover,  thesurface  of  the  tumour  is  irregular 
and  bossy,  and  if  there  is  likewise  dysphagia  and  pain 
in  the  neck,  shooting  up  to  the  side  of  the  head  or 
to  the  shoulders,  then  the  diagnosis  becomes  almost  a 
certainty. 

Involvement  of  skin  and  lymph  glands  affords  but  little 
help  in  the  diagnosis.  The  skin  is  seldom  involved 
even  in  late  stages,  except  in  those  cases  in  which  the 
growth  has  been  punctured  or  incised ;  exceptionally, 
spontaneous  ulceration  of  the  skin  does  however  take 
place. 

By  the  time  that  enlargement  of  the  glands  can  be 
detected,  the  nature  of  the  disease  is  usually  sufficiently 
obvious ;  it  must  be  remembered  that  the  glands  that 
first  become  affected  are  usually  very  deeply  seated,  at 

H 


114  SURGICAL    DIAGNOSIS. 

the  root  of  the  neck,  or  behind  the  sternum,  where  their 
detection  is  well  nigh  impossible. 

When  malignant  disease  occurs,  as  it  often  does,  in  a 
gland  that  is  already  the  seat  of  an  innocent  goitre,  the 
true  nature  of  the  affection  is  apt  at  first  to  be  masked. 

On  the  other  hand,  malignant  disease  may  be  simu- 
lated by  the  rapid  enlargement  of  such  a  goitre  due  to 
the  development  of  a  cyst,  or  to  haemorrhage  into  a 
cyst.  A  rapidly  enlarging  cyst  is  often  attended  by  a 
certain  amount  of  pain.  It  can  generally  be  distin- 
guished from  a  malignant  tumour  by  its  smoothness  ; 
generally  also  by  its  softness,  although  it  must  not  be 
forgotten  that  tense  cysts  may  be  very  hard,  and  that 
some  forms  of  malignant  disease  are  very  soft. 

Inflammation  of  a  goitre  resembles  malignant  disease 
in  that  it  causes  pain,  fixity  and  often  involvement  of 
neighbouring  nerves,  notably  the  recurrent  laryngeal. 


CHAPTER  XII. 

DISEASES  OF  THE  BREAST. 

A  PATIENT  who  seeks  advice  with  regard  to  an  affection 
of  the  breast  generally  does  so  on  account  of  one  or 
other  of  the  four  following  conditions  : 

(a)  Pain.  (5)  Swelling.  (6')  Discharge  from  the 
nipple,  (d)  Some  superficial  affection  of  the  skin,  such 
as  eczema,  ulceration,  &c. 

(a)  Pain. — Pain  in  a  breast  may  be  due  to  disease  in 
the  breast  itself,  or  to  disease  in  some  adjacent  part,  or 
it  may  be  merely  a  referred  pain,  the  primary  source  of 
which  is  in  some  distant  part.  Pain  due  to  local  dis- 
ease is  usually  accompanied  by  some  other  local  sign, 
such  as  swelling  or  tenderness.  Pain  due  to  an  affec- 
tion of  a  neighbouring  part,  such  as  periostitis  of  an 
underlying  rib,  or  inflammation  of  a  pleura,  has  to  be 
diagnosed  by  the  other  signs  and  symptoms  of  these 
affections,  and  by  the  fact  that  the  breast  itself,  when 
lifted  up  or  drawn  gently  away  from  the  chest-wall, 
shows  no  evidence  of  disease. 

It  is  well,  however,  to  remember  that  even  if 
the  breast  be  obviously  diseased,  the  pain  complained 
of  by  the  patient  may,  nevertheless,  be  due  to  some 
other  cause.  Thus  a  patient  with  a  harmless  adenoma 
may  have  severe  pain,  due,  let  us  say,  to  pleurisy.     A 


Il6  SURGICAL   DIAGNOSIS. 

little  care  will,  however,  in  such  a  case,  prevent  any 
mistake. 

We  must  avoid  jumping  too  readily  to  the  conclusion 
that  a  lump  in  the  breast  and  a  pain  in  the  same  part 
are  necessarily  associated  in  the  relation  of  cause  and 
ejffect.  If  a  breast  show  no  sign  whatever  of  disease, 
and  the  patient,  nevertheless,  complains  of  pain  in  it, 
the  most  careful  examination  of  the  spine  and  chest- 
wall  should  be  made,  and  the  viscera  of  the  thorax  and 
abdomen  investigated.  Bilateral  pain  referred  to  the 
breasts  is  not  likely  to  be  caused  by  spinal  caries.  Pain 
in  the  left  breast  is  frequently  associated  with  disease 
of  the  stomach  or  heart.  Pain  in  the  right  breast  may  be 
caused  by  disease  of  the  liver. 

In  the  vast  majority  of  cases,  however,  a  pain  felt  in 
a  breast  is  due  to  disease  of  that  organ. 

Severe  pain  almost  always  indicates  inflammation  ; 
the  pain  being  especially  severe  if  the  inflammation  is 
deep-seated  and  under  tension,  as  in  the  earlier  stages 
of  mammary  abscess.  Tenderness  associated  with  pain 
generally  points  to  inflammation.  A  cyst  which  con- 
tains much  fluid,  and  is  consequently  very  tense,  may 
also  give  rise  to  a  good  deal  of  pain.  But  in  such  a 
case  as  this  it  is  generally  a  transient  inflammation  of 
the  cyst  wall  that  leads  to  increased  secretion  into  the 
cyst  and  so  to  the  pain. 

The  more  chronic  inflammatory  affections  of  the 
breast  may  give  rise  to  a  certain  amount  of  dull  aching 
pain,  which  may  be  difl&cult  to  distinguish  from  the 
pain  due  to  a  malignant  new  growth.  A  pain  which  is 
felt  only  or  chiefly  towards  the  evening  is  likely  to  be 
due  to  inflammation. 

New  growths  of  the  breast,  if  not  inflamed,  rarely 


DISEASES    OF   THE    BREAST.  II7 

give  rise  to  much  pain.  Innocent  growths,  such  as 
adenomata  and  cysts,  rarely  cause  pain,  unless  they 
are  enlarging  rapidly  and  exerting  pressure  upon  sur- 
rounding parts. 

Malignant  growths  tend,  of  course,  to  extend  to  the 
skin,  or  to  the  mucous  surfaces  of  ducts,  and  thus  easily 
become  infected,  inflamed,  and  consequently  painful. 
By  infiltrating  and  involving  nerves  they  may  at  times 
give  rise  to  a  certain  amount  of  pain.  It  is  important 
to  remember  that  it  is  the  inflammation  which  is  fre- 
quently the  cause  of  pain  in  a  new  growth.  Treatment, 
i.e.,  cleansing  with  antiseptics,  will  often  materially 
lessen  the  pain  of  an  ulcerated  new  growth. 

A  slight  amount  of  pricking  or  dragging  pain  is 
often  felt  in  a  case  of  carcinoma  of  the  breast,  and  is 
by  some  considered  to  afford  help  in  diagnosis.  The 
popular  idea  that  cancer  of  the  breast  is  necessarily  a 
painful  affection  is  of  course  wholly  erroneous. 

(h)  Swelling. — A  general  enlargement  of  the  breast 
occurs  normally  at  puberty,  both  in  the  female  and, 
sometimes,  in  the  male  sex.  This  enlargement  may  be 
attended  with  a  slight  degree  of  pain.  The  condition 
is  easily  recognised  by  the  age  of  the  patient.  The 
general  enlargement  of  the  breasts  which  occurs  in 
pregnancy  is  not  likely  to  lead  to  any  error  in  diag- 
nosis. Occasionally  a  cancerous  tumour  occurring 
duriug  pregnancy  may  be  overlooked,  owing  to  its  being 
buried  in  the  enlarged  breast. 

A  general  enlargement  of  the  breast  occurs  in  the 
rare  disease  known  as  hypertrophy  of  the  breast. 
This  occurs  very  rarely  in  the  male  sex.  It  is  most 
common  in  young  women,  and  is  probably  always 
bilateral,   affecting    both    breasts   at   the  same   time. 


Il8  SURGICAL   DIAGNOSIS. 

Cases  of  supposed  hypertrophy  of  one  breast  usually 
prove  to  be  cases  of  large  soft  tumours  (fibro-adenomata 
or  lipomata)  of  the  breast  itself  or  neighbouring 
parts.  Careful  examination  in  such  a  case  will  almost 
always  show  that  the  normal,  although  displaced,  and 
perhaps  flattened,  breast  can  be  felt  resting  upon  the 
tumour,  and  is  more  or  less  separable  from  it. 

A  breast  may  appear  to  be  enlarged  when  it  is  not 
really  large,  but  merely  pushed  forwards  by  something 
behind  it.  A  post-mammary  abscess  is  the  most  common 
cause  of  such  enlargement ;  but  any  kind  of  swelling 
behind  the  breast  may  produce  the  same  effect.  Dis- 
tortion of  the  chest-wall  in  cases  of  lateral  curvature 
'■  of  the  spine,  and  locally  prominent  rib  cartilages,  will 
thus  produce  an  apparent  swelling  of  a  breast. 

General  enlargement  of  one  breast  alone  is  almost 
always  due  to  inflammation,  and  is  usually  seen  in 
women  during  the  period  of  lactation.  Indeed,  any 
enlargement  of  a  breast,  whether  general  or  local,  occur- 
ring during  this  period  should  always  primarily  suggest 
inflammation. 

Acute  inflammation  of  the  breast  is  usually  easily 
recognised  by  the  ordinary  local  and  general  signs  of 
inflammation.  Of  these,  oedema  is  one  of  the  most 
important ;  a  patch  of  oedema,  especially  if  there  be  a 
soft  spot  in  the  centre  of  it,  commonly  indicates  suppu- 
ration. Acute  inflammation  may  be  closely  simulated 
by  the  brawny  form  of  cancer.  Cancer  occurring  in  a 
breast  which  is  enlarged  from  pregnancy  is  apt  to  grow 
rapidly,  and  the  general  swelling  of  the  gland  may 
easily  mask  the  more  characteristic  signs  of  tumour. 
The  adhesion  of  the  swelliug  to  the  skin,  which  is  so 
common  a  feature  of  cancer,  is  simulated  by  the  inflam- 


DISEASES    OF   THE   BREAST.  1 1 9 

matory  hardening  and  fixity  of  the  skin  which  occurs  in 
cases  of  inflammation  both  acute  and  chronic.  The 
absence  of  fever,  and  the  absence  of  tenderness  in  the 
affected  axillary  glands,  both  point  towards  cancer.  On 
the  other  hand,  a  chronic  abscess  deeply  seated  in  a 
lai'ge  breast  may  cause  no  fever  and  but  little  pain  ; 
the  nipple  may  be  deeply  retracted,  and  there  may  be 
considerable  hardness  and  fixity  of  the  skin  over  the 
lump. 

Although  inflammation  is  much  more  common  during 
the  childbeariug  period  than  at  any  other,  it  may  never- 
theless occur  even  in  advanced  age.  It  is  precisely  in 
elderly  women  that  a  hard  and  comparatively  painless 
lump  of  inflammatory  nature  is  likely  to  be  mistaken 
by  a  careless  observer  for  the  more  serious  disease. 

The  presence  of  distinct  nodules  in  the  skin  over  and 
around  the  breast  is  conclusive  of  malignancy. 

Rapid  emaciation  does  not  usually  point  especially 
towards  malignancy,  since  absorption  from  inflammation 
may  easily  cause  this.  Cancer,  on  the  contrary,  not 
uncommonly  advances  to  a  comparatively  late  stage 
before  the  general  health  is  appreciably  affected.  A 
woman  may  appear  to  be  in  robust  health  and  yet  have 
a  hopelessly  advanced  carcinoma  of  the  breast.     - 

A  form  of  inflammation  which  sometimes  closely 
simulates  carcinoma  is  the  tuberculous.  Here  the  signs 
of  inflammation  are  often  ill  marked,  owing  to  the 
chronic  nature  of  the  affection.  There  may  be  consider- 
able induration  of  the  breast.  If  the  skin  be  affected, 
there  may  be  an  indolent  ulcer  tending  slowly  to  extend. 
The  edges  of  the  tuberculous  ulcer  are,  however,  usually 
unijermined,  and  the  discharge  is  more  profuse  and 
purulent.     The  skin  around  a  carcinomatous  ulcer  is 


120  SURGICAL    DIAGNOSIS. 

always  infiltrated  and  hard.  The  axillary  glands  in  a 
case  of  tubercle,  although  usually  enlarged  and  not 
particularly  tender,  lack  the  characteristic  hardness  of 
malignancy.  An  exception  must  be  made,  however,  in 
the  case  of  old  tuberculous  glands,  which  may  be  of 
stony  hardness  owing  to  fibrosis  or  even  calcification. 
The  past  history,  the  family  history,  and  the  presence  of 
tuberculous  lesions  in  other  parts  of  the  body,  may 
afford  help  in  the  diagnosis  of  tuberculous  disease  of 
the  breast. 

The  greatest  difficulty  in  the  diagnosis  between  in- 
flammation and  cancer  is  to  be  seen  in  those  rare  cases 
in  which  a  malignant  tumour  has  become  inflamed,  so 
that  the  signs  and  symptoms  of  inflammation  are  super- 
added to  those  of  carcinoma.  The  presence  of  a  toler- 
ably definite  hard  mass  in  the  breast,  and  the  hard 
enlargement  of  the  axillary  glands,  will  nevertheless 
usually  serve  to  indicate  carcinoma. 

A  somewhat  diffuse  form  of  cancer  occurring  in 
patches  over  a  considerable  area  of  breast  tissue  may 
be  very  difficult  to  distinguish  from  the  chronic  fibroid 
or  inflammatory  condition  often  met  with  in  old  people. 
In  the  absence  of  such  characteristic  signs  of  cancer  as 
local  infiltration  of  neighbouring  parts  and  affection  of 
glands,  the  best  means  of  distinguishing  between  the 
two  affections  is  by  the  greater  hardness  of  the 
malignant  disease.  The  presence  of  small  hard  round 
nodules,  like  large  shot,  in  the  breast  itself,  is  not  un- 
common in  the  simple  fibroid  disease,  the  nodules  being 
small  innocent  cysts.  Sometimes  it  is  impossible  to  make 
a  certain  diagnosis  without  an  exploratory  incision. 

A  single  v/ell-defined  lump  in  the  breast,  which  is 
not  inflammatory,  is  probably  either  a  fibro-adenoma,  a 


DISEASES    OF   THE    BREAST.  12  i 

cyst  or  a  carcinoma.  Sarcoma  is  so  uncommon,  and  so 
difficult  to  diagnose  clinically  from  the  softer  forms  of 
carcinoma,  that  it  need  not  be  considered  here  apart 
from  carcinoma. 

Fibro-adenoma  is  essentially  a  disease  of  early  adult 
life,  and  usually  first  makes  its  appearance  before  the 
age  of  thirty,  that  is,  at  an  age  when  cancer  is  un- 
common. Its  positive  characters  are  roundness,  nodu- 
larity and  slow  growth.  The  older  the  patient  and  the 
older  the  adenoma,  the  more  likelj^  is  the  latter  to 
contain  much  dense  fibrous  tissue,  and  to  be  very  hard. 
It  is  well  not  to  pay  too  much  attention  to  a  history  of 
the  tumour  having  been  noticed  for  a  short  time  only. 
Many  an  innocent  tumour  of  the  breast  has  lain  for 
years  quietly  buried  in  a  big  breast  without  ever 
attracting  attention.  If  a  large  breast  becomes  small, 
as  at  the  menopause  for  instance,  such  a  tumour 
becomes  relatively  much  more  prominent  and  distinct. 
Under  these  circumstances,  the  patient  may  then  in 
perfectly  good  faith  give  a  most  fallacious  and  mis- 
leading history  of  only  short  duration. 

A  single  cyst  is  rounded  and  smooth.  It  is  usually 
distinctly  elastic,  and  may  be  so  soft  as  to  give  rise  to 
a  definite  sense  of  fluctuation,  especially  if  large  or  if 
situated  near  the  surface. 

The  presence  of  one  or  more  small  hard  shot-like 
bodies  elsewhere  in  the  breast  will  suggest  a  cyst,  the 
smaller  bodies  being  similar  cysts  in  an  earlier  stage. 
Such  multiple  cysts  are  not  uncommon  in  elderly 
women  in  whom  the  breast  is  undergoing  involution. 

A  cyst  of  the  breast  is  sometimes  surrounded  by  a 
ring  of  indurated  breast  tissue,  which  obscures  the 
roundness  and  elasticity  of  the   cyst  itself.     In  such 


122  SURGICAL   DIAGNOSIS. 

cases,  the  flatness  of  the  whole  swelling,  together  with 
the  softness  of  its  centre,  sometimes  serves  to  distin- 
guish it  from  carcinoma. 

The  history  of  a  cyst  is  frequently  that  of  a  slowly 
growing  tumour  extending  over  months  or  years.  Not 
uncommonly  the  history  is  a  very  short  one.  Indeed, 
a  rounded  swelling  which  has  attained  a  considerable 
size  in  the  course  of  two  or  three  weeks,  and  which  is 
not  inflammatory,  is  probably  a  cyst. 

In  such  cases  the  cyst  has,  doubtless,  existed  for  a 
long  time,  but  has  attracted  no  attention  until  a  com- 
paratively sudden  effusion  of  fluid  into  it  has  drawn 
attention  to  its  presence.  A  blood-stained  discharge 
from  the  nipple  shows  that  the  cyst  contains  intra- 
cystic  growth,  innocent  or  malignant.  Multiple  cysts 
in  the  breast  produce  an  irregular  mass  or  a  number 
of  separate  rounded  tumours,  the  nature  of  which  is 
usually  not  difficult  to  diagnose.  Cysts  sometimes 
occur  in  the  interior  of  carcinomatous  tumours,  but 
these  seldom  lead  to  errors  of  diagnosis,  since  the  hard 
carcinomatous  growth  around  the  cyst  is  usually  suffi- 
ciently characteristic. 

A  cyst  is  most  likely  to  be  mistaken  for  a  carcinoma 
when  it  is  small,  tense,  and  deeply  seated  in  the 
breast. 

A  carcinoma,  on  the  other  hand,  is  most  likely  to  be 
taken  for  a  cyst  when  it  is  soft  and  does  not  as  yet 
show  any  evidence  of  local  infiltration  or  of  affection 
of  glands. 

A  carcinoma  is  diagnosed  with  certainty  before 
operation  only  when  there  is  evidence  of  local  infiltra- 
tion or  of  glandular  implication.  Adhesion  to  the 
skin,    retraction   of   the  nipple,    and  adhesion   to  the 


DISEASES    OF   THE    BREAST.  1 23 

pectoral  muscle,  are  the  three  principal  signs  of  local 
infiltration.  The  occurrence  of  any  one  or  more  of 
these  depends  largely  upon  the  situation  of  the  tumour, 
the  size  of  the  breast,  and  the  amount  of  fat  surround- 
ing it.  A  tumour  at  the  periphery  of  the  breast  is  not 
so  likely  to  cause  retraction  of  the  nipple  as  one  which 
is  near  that  structure.  A  tumour  situated  at  the 
anterior  or  posterior  surface  of  the  breast  is  more 
likely  to  cause  early  adhesion  to  skin  or  muscle  respec- 
tively, than  one  which  is  in  the  centre  of  the  breast. 
Much  fat  surrounding  the  breast  diminishes  the  liability 
to  adhesion  to  skin  or  muscle.  In  a  fat  person  the 
dimpling  of  the  skin  over  a  deeply-seated  carcinoma  is 
often  as  characteristic  of  carcinoma  as  actual  infiltra- 
tion of  the  skin  would  be. 

In  many  cases  of  early  carcinoma  there  are  no  signs 
of  local  infiltration  or  of  glandular  affection.  In  such 
cases  the  diagnosis  can  seldom  be  absolutely  certain 
until  an  incision  has  been  made  into  the  tumour.  But 
a  probable  diagnosis  can  often  be  made.  The  mere 
presence  of  a  hard  lump  in  the  breast  of  a  woman  over 
thirty  years  of  age  should  raise  a  strong  suspicion  of 
carcinoma,  unless  distinctive  signs  of  cyst,  adenoma,  or 
chronic  inflammation  are  also  present.  If  there  is  any 
doubt  about  the  diagnosis  an  exploratory  incision  will 
usually  clear  this  up.  Occasionally  it  is  necessary  to 
remove  a  portion  of  tumour  and  examine  it  micro- 
scopically before  the  diagnosis  can  be  settled  with 
certainty.  But,  as  a  rule,  the  naked  e3^e  appearances 
as  seen  on  section  are  quite  sufficiently  characteristic. 

(c)  Discharge  from  the  nipple. — Besides  the 
natural  secretion  of  the  breast,  there  may  come  from 
the   nipple    serous  fluid,  pus    or    blood.      In    certain 


124  SURGICAL    DIAGNOSIS. 

inflammatory  conditions  of  the  ducts  there  may  be 
discharge  of  serous  or  purulent  matter.  An  abscess 
opening  into  a  main  duct  will  discharge  pus  at  the 
nipple. 

The  discharge  of  blood  from  the  nipple  indicates 
disease  of  a  duct.  It  usually  indicates  either  a  tumour 
of  the  duct,  such  as  a  duct  j)apilioma  or  a  duct  cancer, 
or  else  that  a  tumour  originating  outside  a  duct  has 
penetrated  the  lumen  of  the  latter.  A  blood-stained 
discharge  from  the  nipple  usually  indicates  duct 
carcinoma.  The  presence  of  a  rather  soft  tumour  and 
the  absence  of  affection  of  the  axillary  glands  generally 
serve  to  distinguish  duct  carcinoma  from  the  more 
serious  forms  of  malignant  disease. 

{d)  The  superficial  affections  of  the  skin  over 
the  breast  and  affections  of  the  nipple  present  but  little 
difficulty  in  diagnosis.  It  is  well  to  remember  that  a 
primary  syphilitic  sore  sometimes  occurs  at  the  nipple 
in  women  who  are  nursing  syphilitic  children  other 
than  their  own. 

There  is  also  a  form  of  malignant  dermatitis  which 
occurs  at  the  nipple  and  gradually  destroys  it  (Paget 's 
disease).  It  is  to  be  diagnosed  by  the  induration  of 
its  base,  which  distinguishes  it  from  simple  eczema, 
and  by  its  slowly  progressive  course. 

Various  other  affections  of  the  skin  may  occur  in 
the  region  of  the  breast,  but  are  not  especially  cha- 
racteristic of  this  part,  and  require  no  special  descrip- 
tion. 


CHAPTER  XIII. 

DISEASES  OF  THE  ABDOMEN— DIAG- 
NOSIS OF  AN  ABDOMINAL  SWELL- 
ING. 

History. — In  ascertaining  the  history  of  an  abdo- 
minal tumour  there  are  two  points  to  which  attention 
should  be  especially  directed. 

I.  Where  did  the  swelling  begin  ? — Has  it 
always  occupied  its  present  position,  or  did  it  begin  in 
one  place  and  gradually  move  to  another  ? 

Information  on  this  point,  if  sufficiently  definite, 
may  be  of  much  help  in  determining  to  which  abdo- 
minal viscus  the  origin  of  the  tumour  is  to  be  assigned. 
Thus  in  the  case  of  a  large  cystic  tumour  supposed  to 
be  either  ovarian  or  hydronephrotic,  a  history  of  the 
tumour  having  been  first  noticed  in  one  or  other  iliac 
region  or  at  any  rate  in  the  lower  part  of  the  abdomen, 
will  point  to  an  ovarian  origin,  while  a  histor}^  of  com- 
mencement in  the  loin  will  naturally  seem  to  indicate 
a  renal  origin.  Similarly  a  tumour  that  was  first 
noticed  near  the  left  costal  margin  and  gradually 
extended  downwards  and  to  the  right  is  likely  to  be  of 
splenic  origin.  Attention  to  the  early  history  of  the 
situation  of  a  tumour  is  particularly  important  in  the 


126  SURGICAL    DIAGNOSIS. 

case  of  those  organs  such  as  the  spleen,  which  are 
likely  to  become  greatly  displaced  from  their  normal 
situation. 

2.  Have  there  been  symptoms  indicating 
derangement  of  the  functions  of  the  organ 
to  which  the  tumour  is  supposed  to  belong  ? 

Marked  diminution  in  the  amount  of  urea  in  the 
urine  may  indicate  renal  disease,  the  vomiting  of 
blood  ma}^  point  to  disease  of  the  stomach,  and  so 
forth. 

Too  much  reliance,  however,  must  not  be  placed 
upon  this  alteration  of  function  as  evidence  of  disease 
of  the  organ  itself.  Vomiting  is  a  symptom  of  many 
abdominal  disorders  besides  that  of  tumours  of  the 
stomach.  Irritability  of  the  bladder  occurs  in  connec- 
tion with  pelvic  affections  other  than  those  of  the 
bladder  itself. 

In  the  diagnosis  between  enlargements  of  the 
kidney  and  of  the  gall-bladder,  the  presence  of  blood 
or  pus  in  the  urine  would  naturally  point  strongly 
towards  kidney.  But  it  must  be  remembered  that  two 
or  more  diseases  may  co-exist :  a  patient  with  slight 
pyuria,  for  example,  may  also  have  a  distended  gall- 
bladder. 

In  every  case  of  abdominal  tumour  it  is  well  to 
inquire  into  the  functions  of  all  the  principal  abdominal 
viscera,  and  to  ask  whether  there  are,  or  have  been, 
any  symptoms  referable  to  the  gastric,  intestinal, 
hepatic,  or  genito-urinary  organs. 

Physical  examination. — During  the  physical 
examination  of  an  abdomen,  the  patient  should  at  first 
lie  upon  his  back  with  the  shoulders  slightly  raised 
and  the  knees  flexed.     The  patient  should  be  told  to 


DISEASES    OF    THE    ABDOMEN.  1 27 

breathe  quietly  and  deeply.  It  is  a  good  plan  to  carry 
on  a  conversation  with  him  during  the  examination, 
so  as  to  distract  his  attention  and  prevent  him  from 
holding  his  breath  or  making  the  abdominal  muscles 
rigid.  Some  portion  of  the  history  of  the  case  may 
be  obtained  in  this  way  while  the  surgeon  is  making 
the  physical  examination. 

Inspection  of  the  abdomen  should  comprise  the 
following  points : 

Is  the  abdomen  enlarged  ?  If  so,  is  the  enlargement 
general  and  uniform,  or  is  it  local  ? 

Is  the  abdominal  wall  retracted  ? 

Do  the  abdominal  muscles  move  freely  with  respi- 
ration, or  are  they  kept  rigid  ? 

Are  the  superficial  veins  enlarged  or  distended  ? 
and,  if  so,  does  the  blood  in  them  flow  in  the  usual 
direction  ? 

If  there  is  a  visible  abdominal  swelling  of  any  kind, 
is  it  stationary,  or  does  it  move  up  and  down  with  the 
respiration  ? 

The  presence  of  any  disease  of  the  skin,  of  an  ulcer, 
sinus,  or  scar,  and  the  condition  of  the  umbilicus, 
are  of  course  points  to  which  attention  should  be 
directed. 

The  relation  of  a  visible  abdominal  swelling  to  the 
muscles  of  the  anterior  abdominal  wall  is  ascertained 
by  putting  these  muscles  into  action.  This  is  done 
by  telling  the  patient  to  fold  his  arms  across  the  chest 
and  then  to  attempt  to  sit  up.  The  contraction  of  the 
muscles,  and  especially  of  the  recti,  will  lead  to  the 
flattening  and  partial  or  total  disappearance  of  a 
swelling  situated  behind  the  muscles.  Swellings  situ- 
ated in  front  of  the  muscles  are  not  affected  at  all  by 


128  SURGICAL    DIAGNOSIS. 

this  movement.  A  swelling  in  the  muscular  wall  is 
variously  affected  according  to  the  exact  position  it 
occupies  and  the  amount  of  muscle  covering  it. 

Palpation. — The  hand  should  be  laid  flat  on  the 
abdomen,  and  the  whole  region  gently,  carefully,  and 
systematically  palpated ;  at  first  superficially,  then 
deeply. 

When  palpating  the  loin,  both  hands  should  be  used  j 
one  placed  in  front,  the  other  behind. 

In  palpating  the  gall-bladder,  kidney,  spleen,  and 
sometimes  other  organs,  it  is  often  advisable  to  turn 
the  patient  partially  over  on  to  his  face.  By  this  means 
the  viscera  are  made  to  fall  towards  the  anterior  ab- 
dominal wall ;  they  may  thus  be  more  easily  felt.  Any 
unusual  tenderness,  whether  superficial  or  deep,  should 
be  noticed. 

In  palpating  for  the  spleen,  liver,  or  gall-bladder, 
the  fingers  should  be  pressed  deeply  into  the  hypo- 
chondriac regions,  and  the  patient  told  to  take  a  deep 
breath,  so  as  to  drive  the  viscera  down  ujDon  the  ex- 
amining fingers. 

In  palpation  of  the  kidney,  the  surgeon  should  sit 
facing  the  patient,  and  place  one  hand  on  the  loin  and 
the  other  upon  the  abdomen  ;  an  enlarged  or  move- 
able kidney  can  be  grasped  between  the  two  hands. 
Except  in  emaciated  subjects,  or  persons  in  whom  the 
abdominal  wall  is  unusually  lax,  the  normal  kidney 
cannot  be  felt. 

General  angesthesia,  by  producing  relaxation  of  the 
muscular  wall,  is  of  great  assistance  in  deep  palpation 
of  the  abdomen. 

Percussion. — Percussion  is  used  chiefly  (i)  to 
define  the  limits  of  the  liver  and  spleen  ;  (2)  to  detect 


DISEASES    OF   THE   ABDOMEN.  1 29 

the  presence  of  fluid  ;  (3)  to  ascertain  whether  certain 
apparently  solid  or  liquid  tumours  contain  gas  or  not. 

Over  the  liver  and  spleen  there  are  normal  areas  of 
dulness ;  the  rest  of  the  front  and  sides  of  the  abdomen 
should  be  resonant.  Dulness  anywhere  means  the  pre- 
sence of  solid  or  liquid  in  contact  with  the  abdominal 
wall.  It  should  be  remembered  that  even  a  large  col- 
lection of  fluid  may  give  a  resonant  note  when  intestine 
is  mixed  up  with  it.  A  large  air-containing  cavity,  i.e., 
dilated  stomach  or  colon,  may  give  a  higher  resonant 
note.  The  "  bell  sound "  may  be  obtained  over  such 
cavities. 

Percussion  is  of  most  value  when  the  abdomen  is 
tensely  distended,  and  palpation  of  the  viscera  is  con- 
sequently not  easily  effected.  Percussion  of  the  colon 
in  the  loin,  with  the  patient  in  the  knee-elbow  position, 
affords  a  valuable  means  of  distinguishing  between 
a  distended  gall-bladder  and  an  enlargement  of  the 
kidney. 

Auscultation  is  not  of  much  value  except  for  the 
detection  of  aneurysmal  bruit,  of  local  friction,  and  for 
the  detection  of  splashing  and  other  sounds  in  hollow 
viscera  containing  gas  and  liquid. 

General  and  uniform  Enlargement  of  the 
Abdomen 

is  due  to  one  or  other  of  the  following  conditions : 

I.  Obesity,  often  associated  with  atony  and  laxity 
of  the  intestinal  walls  and  accumulation  of  flatus. 

Mere  obesity  is  usually  easily  diagnosed  by  the  thick- 
ness of  the  subcutaneous  layer  of  fat,  by  the  general 
appearance  of  the  patient,  by  the  absence  of  tension  in 

I 


130  SURGICAL   DIAGNOSIS. 

the  abdomen,  and  by  the  depth  of  the  umbilicas.  The 
existence  of  obesity  should  not,  however,  deter  the 
surgeon  from  making  a  very  thorough  examination  of 
the  whole  abdomen,  with  the  view  of  finding  whether 
the  enlargement  of  the  abdomen  is  not  also  in  part 
due  to  some  other  condition.  The  existence  of  obesity 
naturally  adds  considerably  to  the  difficulty  of  the 
examination. 

2.  Gaseous  distension  of  the  intestines. — 
This  may  be  due  merely  to  atony  of  the  intestinal 
walls  and  undue  decomposition  of  the  intestinal  con- 
tents, as  in  the  tumid  abdomen  of  rickets,  cretinism, 
and  other  conditions  associated  with  chronic  gastro- 
intestinal disturbance.  Distension  of  the  abdomen  from 
these  causes  does  not  produce  any  great  amount  of 
tension,  and  this  fact  serves  to  distinguish  this  variety 
of  distension  from  the  far  more  serious  form  of  dis- 
tension due  to  accumulation  of  gas  above  a  stricture 
or  other  form  of  mechanical  obstruction  of  the  intes- 
tine. 

The  distension  due  to  the  latter  cause  is  most  marked 
when  the  obstruction  is  low  down  in  the  large  intes- 
tine and  is  chronic  in  its  course.  Under  these  conditions 
the  distension  may  be  enormous  and  the  tension  very 
great. 

■  A  third  form  of  gaseous  distension,  and  a  very 
common  one,  is  that  which  accompanies  peritonitis  and 
other  forms  of  inflammatory  trouble  in  the  abdomen. 

3.  Fluid  in  the  peritoneal  cavity. — {a)  Liquid. 
(&)  Gas. 

{a)  Liquid  (Ascites) . — The  shape  of  an  abdomen 
that  is  much  enlarged  from  the  presence  of  free  liquid 
is  usually  very  characteristic.     The  weight  of  the  liquid 


DISEASES    OF   THE    ABDOMEN.  131 

causes  the  abdominal  walls  to  bulge  laterally ;  the 
anterior  surface  of  the  abdomen  is  more  or  less  flattened 
out.  If  the  amount  of  fluid  is  large,  a  wave  of  fluctuation 
can  be  made  to  pass  between  the  two  hands  placed  one 
on  either  side  of  the  abdomen  ;  but  this  is  less  character- 
istic of  free  fluid  than  of  fluid  contained  in  a  localised 
large  cavity,  such  as  that  of  an  ovarian  cyst.  In  ex- 
amining for  a  wave,  the  hand  of  a  second  person  should 
be  pressed  vertically  upon  the  front  of  the  abdomen  to 
steady  it  and  prevent  transmission  of  impulse  along  the 
abdominal  wall. 

Alteration  in  the  limits  of  dulness,  according  to  the 
position  of  the  patient,  is  an  important  and  valuable 
sign  of  liquid  free  in  the  abdominal  cavity.  The  liquid 
naturally  occupies  the  lower  part  of  the  space  in  which 
it  lies.  Consequently  free  fluid  in  the  abdomen  gives 
dulness  in  the  flanks  and  hypogastrium,  while  the  upper 
and  central  parts  of  ^ the  abdomen,  occupied  by  gas- 
containing  viscera  floating  upon  the  liquid,  yield  a 
resonant  note.  When  the  patient  is  turned  on  one  side, 
the  opposite  flank,  now  the  highest  part,  becomes 
resonant. 

In  the  case  of  a  large  liquid-containing  cyst,  such  as 
an  ovarian,  the  intestines  are  pushed  upwards  and  into 
the  flanks.  Consequently  these  regions  are  resonant, 
while  the  hypogastric  and  umbilical  regions,  occupied 
by  the  cyst,  are  dull. 

It  should  be  remembered  that  even  when  the  abdomen 
contains  much  liquid  the  flanks  may  not  be  wholly  dull 
if  the  fixed  portions  of  the  colon  (ascending  and  descend- 
ing) happen  to  be  distended  with  gas. 

The  diagnosis  of  liquid  in  the  abdomen  is  some- 
times confirmed,  if  necessary,  by  tapping ;  but  this,  as  a 


132  SURGICAL   DIAGNOSIS. 

diagnostic  measure,  is  not  advisable,  owing  to  the  risk 
of  wounding  intestine  and  causing  serious  harm. 

The  liquid  that  is  found  free  in  the  abdominal  cavity 
may  be  of  any  of  the  following  varieties  : 

(i)  The  ordinary  clear,  ascitic  fluid  (much  the  most 
common).  The  ascites  maybe  merely  a  part  of  a  general 
anasarca;  in  this  case  oedema  of  the  lower  limbs,  scrotum, 
or  other  parts  may  be  present,  and  attention  to  the  state 
of  the  heart,  lungs,  or  kidneys  will  reveal  the  cause  of 
the  ascites.  The  ascites  may  be  due  to  some  local  (abdo- 
minal) cause.  Of  this  the  most  common  is  probably 
cirrhosis  of  the  liver,  or  some  other  obstruction  to  the 
portal  circulation.  It  is  important  to  bear  in  mind  that 
obstruction  to  the  venous  circulation  in  any  of  the 
abdominal  viscera  may  lead  to  exudation  of  serum  from 
the  congested  blood-vessels,  and  thus  produce  ascites. 
Apart  from  disease  of  the  heart,  lungs,  liver,  and 
kidneys,  and  from  ascites  due  to  passive  congestion, 
ascites  is  most  often  due  to  chronic  inflammation  of 
the  peritoneum  (tuberculous  or  simple),  or  to  malignant 
disease. 

(ii)  The  ascitic  fluid  may  be  blood-stained.  Blood- 
stained ascitic  fluid,  if  not  due  to  injury,  generally  indi- 
cates malignant  disease  either  of  the  peritoneum  itself, 
or  more  often  of  some  viscus  the  disease  of  which  has 
penetrated  the  peritoneum.  Very  rarely  blood-stained 
fluid  is  found  in  connection  with  tuberculous  disease. 
It  is  also  seen  occasionall}^  in  cases  of  acute  strangula- 
tion of  any  viscus,  but  especially  of  the  small  intestine. 
In  cases  of  acute  strangulation  of  an  abdominal  viscus 
the  amount  of  peritoneal  fluid  is  usually  not  very  great. 
(iii)  The  contents  of  a  ruptured  cyst  (usually  ovarian) 
may  be  present   in   the    abdominal  cavity  in   such   a 


DISEASES    OF   THE    ABDOMEN.  1 33 

quantity  as  to  simulate  ordinary  ascites.  In  these  cases, 
however,  the  fluid  usually  consists  in  part  also  of  inflam- 
matory secretion  from  the  peritoneum.  The  fluid  is 
characterised  by  its  viscidity. 

(iv)  In  cases  of  injury  to  the  liver,  spleen  or  other 
viscera,  blood  may  be  found  in  large  quantity  in  the 
peritoneal  cavity.  Urine  and  even  bile  may  also  be 
present  in  considerable  quantities  after  rupture  of  the 
bladder  and  gall-bladder  respectively. 

(v)  Oases  in  which  the  peritoneal  fluid  presents  a 
milky  appearance  (chylous  ascites)  are,  in  this  country, 
so  rare  as  to  be  of  very  little  practical  importance,  and 
the  diagnosis  usually  presents  no  difficulty, 

(b)  Gas. — Free  gas  in  the  peritoneal  cavity  practically 
always  means  perforation  of  a  gas-containing  viscus,  and 
is  consequently  of  very  grave  import. 

The  diagnosis  is  based  partly  upon  the  distension  and 
hyper-resonance  of  the  whole  abdomen,  but  mainly  upon 
the  absence  of  normal  liver  dulness. 

Absence  of  liver  dulness  is  occasionally  due  to  intes- 
tines lying  in  front  of  the  liver,  but  this  is  exceedingly 
rare. 

Great  diminution,  or  even  absence,  of  liver  dulness 
may  be  observed  in  cases  in  which,  from  atrophy  or 
other  cause,  the  liver  is  exceedingly  small. 

4.  Tumours  springing  from  one  of  the 
abdominal  organs  occasionally  attain  such  an  enor- 
mous size  as  to  practically  fill  the  abdomen  and  thus  to 
cause  an  appearance  of  general  and  uniform  enlarge- 
ment. By  far  the  commonest  of  such  tumours  is  the 
ovarian  cyst,  but  occasionally  a  tumour  of  the  uterus 
(fibroid)  and  kidney  (hydronephrosis)  will  attain  similar 
dimensions. 


134  SURGICAL    DIAGNOSIS. 

In  all  these  cases,  however,  it  will  generally  be  found 
on  careful  examination  that  the  enlargement  is  not 
strictly  uniform.  Careful  attention  to  the  relative 
positions  of  dull  and  resonant  areas  and  to  the  presence 
or  absence  of  symptoms  referable  to  individual  viscera 
will  generally  give  the  clue  to  a  correct  diagnosis. 

5.  A  combination  of  any  one  or  more  of  the 
above  with  any  of  the  local  swellings  described  in  the 
following  section,  e.g.,  malignant  disease  of  the  ovary 
with  ascites,  chronic  intestinal  obstruction  with  peri- 
tonitis, &c. 

In  these  cases  there  may  be  the  greatest  difficulty  in 
diagnosis,  since  the  distension  caused  by  one  condition 
may  entirely  mask  the  physical  signs  of  the  other. 

The  best  way  to  arrive  at  the  truth  is  to  consider 
carefully,  (i)  how  far  the  existing  signs  and  symptoms 
can  be  explained  by  one  or  other  of  the  above  con- 
ditions ;  and  (ii)  what  signs  and  symptoms  are  present 
which  can  not  be  explained  by  them,  and  for  which, 
therefore,  some  other  explanation  must  be  sought. 


Local  Swelling  of  the  Abdomen. 

In  investigating  a  local  abdominal  swelling  its  situ- 
ation is  the  first  point  that  we  have  to  determine. 
We  may  consider  separately — 

1.  Swellings  in  the  anterior  abdominal  wall. 

2.  Swellings  behind  the  anterior  abdominal  wall. 

I .  Swellings  in  the  anterior  abdominal  wall 

may  be  in  the    skin   or    subcutaneous  tissue,  in  the 
muscular  and  aponeurotic  layers,  or  behind  the  muscles. 


DISEASES    OF    THE    ABDOMEN.  1 35 

Swellings  in  the  skin  or  subcutaneous 
tissue  are  generally  markedly  prominent,  and  their 
free  mobility  upon  the  muscles  will  usually  serve  to 
distinguish  them  from  swellings  of  deeper  origin. 

To  test  the  mobility  of  a  swelling  upon  the  abdo- 
minal muscles,  these  latter  should  be  put  into  action 
(by  telling  the  patient  to  attempt  to  sit  up).  If  the 
swelling  can  then  be  moved  freely  upon  the  con- 
tracted muscles,  it  is  not  connected  with  them  or 
with  their  fibrous  aponeuroses. 

Such  swellings  do  not  differ  essentially  from  those 
of  the  skin  and  subcutaneous  tissue  in  other  parts  of 
the  body,  and  need  not  be  further  discussed  here. 
Swellings  originating  in  skin  or  subcutaneous  tissue 
may,  however,  become  secondarily  adherent  (by  inflam- 
mation or  infiltration  of  new  growth)  to  the  muscles, 
aud  their  movement  will  then  be  restricted  according 
to  the  degree  and  extent  of  such  fixation. 

Local  and  prominent  swellings,  such  as  ventral 
hernias,  which  are  obviously  mainly  superficial  to  the 
muscles,  may  appear  to  move  more  or  less  upon  them 
and  yet  be  attached  by  a  comparatively  narrow 
pedicle  to  the  abdominal  muscles,  or  to  the  structures 
behind  them.  A  large  ventral  or  umbilical  hernia  may 
behave  in  this  manner. 

The  small  lobulated  tumours  which  are  often  seen  in 
the  epigastric  region  in  elderly  people  and  which  have 
most  of  the  characters  of  subcutaneous  lipomata  are 
likely  to  be  attached  in  this  way  to  the  abdominal  wall; 
they  will  generally  prove  to  be  herniated  portions  of 
subperitoneal  fat.  Occasionally  they  have  a  peritoneal 
covering,  and  are  true  ventral  hernise  containing 
omentum. 


136  SURGICAL    DIAGNOSIS. 

Swellings  in  the  muscular  and  aponeurotic 
layers  of  tlie  anterior  abdominal  wall  are  not 
common. 

Tumours,  especially  sarcomata,  may  arise  in  any 
part  of  the  abdominal  wall,  and  are  generally  dis- 
tinguished from  inflammatory  swellings  by  their  ex- 
treme hardness  and  definite  outline,  and  by  the  absence 
of  tenderness. 

A  form  of  tumour  not  very  uncommon  in  women  is 
the  dense  fibroma  that  springs  from  the  aponeurosis  of 
the  external  oblique,  generally  near  Poupart's  ligament. 
Its  slow  growth  and  its  hardness  usually  suffice  for  the 
diagnosis. 

Blood  cysts,  due  to  rupture  of  some  of  the  muscular 
fibres,  are  occasionally  seen  in  this  region ;  they  occur 
especially  within  the  sheath  of  the  rectus.  The  abrupt 
limitation  on  the  outer  side  of  the  edge  of  the  rectus 
sheath  may  afford  a  clue  to  the  diagnosis. 

Inflammatory  swellings  in  the  same  region  may 
closely  simulate  them,  but  have  usually  some  deeper 
origin. 

Such  are  the  very  common  inflammatory  swellings  of 
the  abdominal  wall,  which  have  their  origin  in  diseases 
of  the  organs  or  cellular  tissue  of  the  pelvis,  iliac  fossa 
or  loin. 

All  inflammatory  swellings  which  do  not  clearly  move 
upon  the  abdominal  muscles  should  be  suspected  to 
have  some  connection  with  the  interior  of  the  pelvis  or 
abdomen,  unless  they  have  distinctive  characters  of  their 
own,  or  can  be  proved  to  be  not  so  connected. 

Inflammatory  swellings  at  the  lower  part  of  the 
abdomen,  in  the  neighbourhood  of  Poupart's  ligament, 
are   very  common,   and   frequently  originate   in  some 


DISEASES    OF  THE    ABDOMEN.  1 37 

disease  of  the  interior  of  the  pelvis  or  abdomen.  A 
careful  examination  of  the  pelvic  viscera  may  throw 
much  light  on  their  origin.  Similarly,  inflammatory 
swellings  in  the  upper  part  of  the  abdomen  may  origi- 
nate in  disease  of  the  liver,  gall-bladder,  stomach,  spleen 
or  thorax,  and  attention  should  be  directed  especially 
to  any  symptoms  indicative  of  disease  of  those  parts. 
Inflammatory  swellings  at  or  near  the  umbilicus  are 
frequently  due  to  extension  of  inflammation  from  the 
peritoneal  cavity  (as  in  tuberculous  peritonitis,  malig- 
nant disease  of  the  transverse  colon,  &c.). 

It  is  by  no  means  uncommon  for  a  carcinoma  of  the 
large  intestine  to  show  the  first  definite  sign  of  its 
presence  in  the  form  of  a  deep-seated  inflammatory 
swelling  of  the  abdominal  wall. 

In  these  cases  the  slow  perforation  of  the  lumen  of 
the  bowel  leads  to  the  adhesion  of  this  to  the  abdominal 
wall  and  the  gradual  extension  of  inflammation  towards 
the  surface. 

Careful  questioning  in  such  a  case  will  generally 
elicit  a  history  of  some  symptoms  more  or  less  definitely 
referable  to  the  intestine. 

Swellings  then  which  come  through  the  abdominal 
wall  from  the  interior  of  the  peritoneal  cavity  com- 
prise— 

(i)  Hernise  (ventral  and  other).* 

(ii)  Collections  of  pus,  originating  in  some  intra- 
abdominal disease  and  perforating  the  muscular  layers. 
Except  in  the  case  of  stout  subjects,  the  diagnosis  is 
seldom  difficult. 

(iii)  New  growths  springing  from  the  interior  of  the 

*  For  the  diagnosis  see  chap.  xvii. 


138  SURGICAL    DIAGNOSIS. 

abdomen  and  perforating  the  abdominal  wall  (uncommon 
except  at  the  umbilicus). 

Swellings  springing  from  the  anterior 
abdominal  wall  behind  the  muscles  cannot  be 
distinguished  by  their  physical  signs  alone  from  swell- 
ings originating  in  an  abdominal  viscus,  and  secondarily 
adherent  to  the  muscles. 

In  both  caseSj  when  the  muscles  are  put  into  action, 
the  mass  becomes  less  distinct  to  sight  and  touch ;  the 
mass  cannot  be  moved  laterally,  or  in  any  way  separated 
from  the  muscles ;  it  can,  however,  if  of  moderate  size 
and  not  extending  as  far  back  as  the  posterior  abdominal 
wall,  be  made  to  move  in  an  antero-posterior  direction 
with  the  muscles.  The  hand  should  be  laid  flat  upon 
the  swelling  and  then  suddenly  pressed  backwards. 
The  backward  displacement  of  the  mass  with  the 
muscles,  and  its  subsequent  and  immediate  return 
with  them  to  the  original  position,  indicate  attachment 
to  the  abdominal  wall. 

This  test  is  of  most  use  when  the  swelling  is  near  the 
centre  of  the  abdomen,  that  is  where  the  abdominal  wall 
is  capable  of  the  greatest  amount  of  movement. 

Swellings  springing  from  the  back  of  the  anterior 
abdominal  wall  are  rare.  They  include  a  few  cases 
of  new  growth  originating  in  the  posterior  fibrous 
layers. 

The  most  common  growth  in  this  situation  is,  however, 
a  secondary  mass  of  new  growth  in  the  parietal  peri- 
toneum. The  presence  of  other  secondary  growths 
elsewhere,  and  evidence  of  the  existence  of  a  primary 
growth,  probably  somewhere  in  the  abdomen,  will 
generally  be  sufficient  for  a  correct  diagnosis.  Intra- 
peritoneal growths  secondarily  adherent  to  the  anterior 


DISEASES    OF    THE    ABDOMEN.  1 39 

abdominal  wall  (such  as  a  carcinoma  of  the  transverse 
colon)  present  the  same  physical  signs  as  those  which 
originate  in  the  back  of  the  anterior  abdominal  wall. 
The  diagnosis  has  to  be  made  chiefly  by  the  special  signs 
accompanying  lesions  of  the  viscus,  whether  attached 
to  the  abdominal  wall  or  not. 

2.  Swellings  behind  the  anterior  abdominal 
■wall. 

There  is  usually  but  little  difficulty  in  determining 
that  an  abdominal  swelling  is  situated  behind  the 
muscles  of  the  abdominal  wall.  By  putting  the  abdo- 
minal muscles  into  action,  their  relation  to  the  swelling 
is  determined  by  sight  or  by  touch. 

Deep-seated  tumours  present  no  difficulty  as  regards 
this  point.  The  free  movement  of  the  abdominal  wall 
in  front  of  them  renders  their  deep  situation  evident. 
Many  abdominal  tumours  permit  also  of  a  consider- 
able degree  of  passive  movement,  or  of  movement 
during  respiration,  and  this  mobility  alone  is  usually 
sufficient  to  prove  that  they  lie  behind  the  abdominal 
wall. 

Given  that  a  tumour  is  behind  the  anterior  abdominal 
wall,  the  next  point  to  determine  is  whether  it  is — 

(a)  In  or  connected  with  one  of  the  abdominal  viscera. 

(h)  In  the  peritoneal  cavity  itself. 

(c)  Behind  the  peritoneum  {i.e.^  in  the  retroperitoneal 
tissue,  or  in  the  posterior  abdominal  wall).  Each  of 
these  must  be  considered  separately. 

{a)  Swellings  connected  with  one  of  the  ab- 
dominal viscera  will  be  discussed  in  chapter  xiv. 

(3)Swellings  in  the  peritoneal  cavity  itself.* 

Solid  swellings  in  this  region  are  so  rare  as  to  be  of 

*  It  is  scarcely  necessary  to  remind  the  reader  that  the  peritoneum 


140  SURGICAL    DIAGNOSIS. 

no  practical  importance  whatever.  Occasionally  smooth 
hard  masses  of  fibrous  tissue,  or  even  of  cartilage,  are 
found  free  in  the  peritoneal  cavity  ;  occasionally  primary 
new  growths  springing  from  the  wall  of  the  cavity  may 
project  into  its  interior. 

The  only  really  important  localised  swellings  that 
are  found  strictly  within  the  peritoneal  cavity  are 
encysted  collections  of  fluid,  either  (i)  serous  fluid 
(localised  ascites) ;  (ii)  blood,  rare  except  in  the 
pelvis  (pelvic  haematocele) ;  or,  far  more  common  and 
important,  (iii)  pus. 

(i)  Localised  collections  of  serous  fluid  are  some- 
times found  in  the  peritoneal  cavity  as  the  result  of 
a  chronic  inflammation  of  a  portion  only  of  the  peri- 
toneum ;  sometimes  they  are  the  remains  of  an  ascites 
that  has  once  been  general.  Bands  of  adhesion  uniting 
viscera,  chiefly  intestines  and  great  omentum,  to  one 
another,  may  divide  the  peritoneum  into  spaces  in 
which  fluid  may  collect. 

A  large  space  of  this  kind  becoming  filled  with  clear 
fluid  may  present  itself  in  the  form  of  a  very  obvious 
and  sometimes  most  puzzling  swelling,  which,  according 
to  its  situation,  may  simulate  almost  any  other  abdo- 
minal tumour.  Usually,  however,  the  irregularity  of 
these  tumours,  and  the  fact  that  they  have  not  the 
shape  and  do  not  occupy  quite  the  ordinary  position  of 
swellings  of  a  single  viscus,  will  help  in  the  diagnosis. 
Following,  as  they  usually  do,  a  general  chronic  peri- 
tonitis (often  tuberculous  in  nature),  the  previous  history 
and  the  presence  of  bands  or  lumps  in  other  parts  of 
the  peritoneal  cavity  may  help  in  the  diagnosis. 

is  a  closed  sac,  which,  in  the  uormal  conrlition,  contains  nothing  at 
all.    The  abdominal  viscera  lie  outside  the  peritoneal  cavity. 


DISEASES    OF   THE    ABDOMEN.  141 

(ii)  Blood  extra vasated  into  the  general  peritoneal 
cavity  as  the  result  of  injury  is  usually  rapidly  ab- 
sorbed. In  the  case  of  extensive  haemorrhages  into 
the  lesser  peritoneal  cavity,  however,  the  blood  occa- 
sionally remains  to  form  a  large  blood  cyst.  These 
cysts  will  be  discussed  on  p.  142.  Retro-uterine  hsema- 
tocele  also  affords  an  example  of  an  effusion  of  blood, 
which  is  absorbed  but  slowly. 

(iii)  Pus. — The  diagnosis  of  an  abscess  within  the 
peritoneal  cavity  may  present  great  difficulties.     If  the 
abscess  be  near,  or  in  contact  with,  the  anterior  abdo- 
minal v^^all,  if  the  latter  be  not  very  thick  and  its  muscles 
not  too  rigid,  and  if  the  amount  of  pus  be  considerable, 
then  fluctuation  may  be  evident  and  diagnosis  is  facili- 
tated.    More  often,  however,  and  especially  in  the  case 
of  deeply-seated  abscesses,  no  sense  of  fluctuation  can  be 
obtained.     A  more  or  less  distinct  lump  is  all  that  can 
be  felt.     There  is  little  or  no  movement,  since  it  is 
fixed  by  surrounding  inflammatory  adhesions.     Tender- 
ness  may   be    a    valuable    indication.      Elevation    of 
temperature  and  other  general    signs  of  suppuration 
may  be  present,  but  it  must  be  remembered  that  many 
even    large   abdominal    abscesses   are   unattended   by 
fever.     Temperature  depends  upon  the  absorption  of 
inflammatory  products  (toxins),  rather  than   upon  the 
accumulation  of  pus.     Severe  constitutional  symptoms 
may  be  present  before  any  definite  collection  of  pus 
has  formed ;  on  the  other  hand,  an  abscess  surrounded 
by  a  well-marked  barrier  of  lymph  may  give  rise  to  no 
absorption,  and  consequently  no  elevation  of  tempera- 
ture.    An  abscess  of  this  kind  connected  with  subacute 
or  chronic  appendicitis  is  not  uncommonly  attended  by 
a  normal  or  subnormal  temperature. 


142  SURGICAL   DIAGNOSIS. 

The  early  history  of  the  case  is  of  great  importance 
in  the  diagnosis  of  an  intra-peritoneal  abscess.  Most 
of  these  abscesses  occur  as  the  result  of  a  perforation 
of  some  hollow  viscus,  most  often  the  appendix  vermi- 
formis. 

Collections  of  fluid  in  the  lesser  peritoneal 
cavity  are  somewhat  uncommon  ;  they  give  rise  to 
large  rounded  tumours  situated  in  the  upper  and  left 
part  of  the  abdomen.  They  comprise  blood  cysts,  the 
result  of  some  abdominal  injury,  generall}^  a  severe 
one,  and  collections  of  fluid,  the  result  of  perforation 
of  an  ulcer  on  the  posterior  wall  of  the  stomach.  The 
fluid  in  the  latter  case  consists  partly  of  the  acid  con- 
tents of  the  stomach  with  food  dSbris,  and  partly  of 
the  products  of  inflammation,  which  may  be  serous, 
sero-purulent,  or  purulent.  The  diagnosis  of  fluid  en- 
cysted in  the  lesser  peritoneal  cavity  is  made  partly 
from  the  shape  and  situation  of  the  tumour,  partly  by 
observing  the  relation  which  it  bears  in  the  stomach 
and  transverse  colon  when  distended,  and  partly  by  the 
history  of  the  case. 

The  differential  diagnosis  between  the  two  depends 
upon  the  history  of  the  case,  or,  after  abdominal  section, 
upon  the  examination  of  the  fluid  contained  in  the 
cavity. 

As  regards  physical  characters,  the  tumour  which  most 
closely  resembles  a  distended  lesser  peritoneal  sac  is  a 
large  cyst  of  the  pancreas.  The  diagnosis  is  frequently 
impossible  until  after  abdominal  section  has  been  per- 
formed and  the  contents  of  the  cyst  have  been  evacuated. 
The  alkaline  nature  of  the  fluid  in  a  pancreatic  cyst 
affords  the  best  means  of  distinguishing  it  from  fluid 
having  a  gastric  origin. 


DISEASES    OF   THE   ABDOMEN.  1 43 

(c)  Swellings  situated  behind  the  perito- 
neum (in  the  retroperitoneal  cellular  tissue  and  ab- 
dominal wall). 

Swellings  involving  the  kidney,  suprarenal  capsule, 
and  pancreas,  will  be  discussed  with  the  other  abdominal 
viscera. 

The  remaining  swellings  in  this  region  include  : 

(i)  Inflammatory  swellings  (abscess). 

(ii)  Aneurism  of  the  abdominal  aorta. 

(iii)  Enlargements  of  lumbar  lymphatic  glands. 

(iv)  New  growths  (chiefly  sarcoma)  springing  from 
the  vertebrae,  fasciae,  muscles,  &c. 

(v)  Earely  blood  cysts,  collections  of  urine,  &c. 

The  diagnosis  of  swellings  in  this  region  is  made 
by  their  deep  situation,  by  their  fixity,  by  their  ten- 
dency to  displace  forward  such  structures  as  the 
kidney,  or  abdominal  aorta  behind  which  they  may  lie, 
and  (especially  in  the  cases  of  new  growths  and 
inflammatory  swellings)  by  the  involvement  of  lumbar 
nerves. 

Examination  of  the  back  may  also  help  in  the  diag- 
nosis if  the  swelling  happens  to  be  making  its  way 
through  the  posterior  abdominal  wall  or  to  be  causing 
a  bulging  of  this  in  the  space  between  the  last  rib,  the 
lumbar  spine,  and  the  crest  of  the  ilium. 

By  far  the  most  common  of  all  retroperitoneal  swel- 
lings is  an  abscess,  generally  connected  with  disease  of 
the  spine  or  the  kidney,  less  commonly  with  the  large 
intestine,  appendix,  or  some  other  abdominal  or  pelvic 
viscus. 

The  diagnosis  of  retroperitoneal  abscess  depends 
largely  upon  the  diagnosis  of  the  primary  cause,  to- 
gether perhaps  with  elevation  of  temperature  and  other 


144  SURGICAL   DIAGNOSIS. 

general  evidence  of  suppuration.  It  must  be  remem- 
bered, however,  that  many  retroperitoneal  abscesses  are 
essentially  chronic  in  nature,  and  are  often  wholly  un- 
attended by  elevation  of  temperature.  Such  is  usually 
the  case,  for  example,  with  the  ordinary  chronic  abscess 
accompanying  tuberculous  disease  of  the  spine. 


CHAPTER  Xiy. 

DISEASES  OF  THE  ABDOMEN  {continued). 
ENLARGEMENT   OF  A  SINGLE   ORGAN. 

Very  many  abdominal  tumours  consist  of  an  enlarge- 
ment of  a  single  organ,  the  liver,  spleen,  kidney,  &c. 

The  enlargement  may  be  uniform,  as  in  the  case  of 
a  hypertrophied  spleen  or  distended  gall-bladder,  or 
lardaceous  liver ;  or  it  may  be  local  as  in  the  case  of  a 
hydatid  of  the  liver  or  a  fibroid  of  the  uterus. 

The  first  step  towards  diagnosis  has  been  made  when 
it  can  be  shown  that  an  abdominal  tumour  involves  a 
single  organ. 

Diagnosis  as  regards  this  point  is  usually  simple  in 
proportion  as  the  enlargement  is  considerable,  and 
affects  the  whole  organ  uniformly. 

There  are  three  principal  means  which  lead  us  to 
assign  an  abdominal  swelling  to  a  particular  organ. 

I.  It  may  occupy  more  or  less  exactly  the  normal 
situation  of  the  organ,  and  bear  similar  relations 
to  surrounding  parts. 

It  must  be  remembered,  however,  that  a  swell- 
ing originating  near  an  abdominal  viscus  may  displace 
it  and  come  to  occupy  its  situation  ;  thus  a  chronic 
abscess   in    the    loin   may,   as    regards    its    situation, 

K 


146  SURGICAL    DIAGNOSIS. 

resemble  very  closely  a  swelling  of  the  kidney,  the 
latter  organ  being  displaced  forwards  or  in  some  other 
direction.  Care  should  be  taken  therefore,  before 
assigning  a  swelling  to  a  particular  organ  on  account 
of  its  situation  alone,  to  make  sure  that  this  organ 
does  not  exist  in  some  other  part  to  which  it  bas  been 
displaced  by  the  abnormal  swelling. 

II.  It  may  preserve  more  or  less  accurately  the 
characteristic  shape  of  the  organ.  Thus,  a  movable 
swelling  which  presents  a  smooth  convex  surface  on 
one  aspect  and  a  flat  or  concave  surface  on  the  other, 
and  has  a  sharp,  well-defined  border  with  two  or  three 
well-marked  notches  upon  it,  can  scarcely  fail  to  be  a 
spleen,  in  whatever  part  of  the  abdomen  it  may  be 
found.  In  the  case  of  such  a  tumour  being  found  far 
away  from  the  normal  situation  of  a  spleen,  the  diagnosis 
would  be  confirmed  by  the  absence  of  the  normal 
splenic  dulness. 

III.  Quite  apart  from  the  physical  characters  of  the 
swelling  itself  there  may  exist  special  symptoms 
which  point  definitely  to  disease  of  a  particular  organ  ; 
such  are  alterations  in  the  urine,  pointing  to  the  kidney 
or  bladder ;  uterine  hgemorrhage,  jaundice,  diarrhoea  or 
hasmatemesis,  suggesting  respectively  disease  of  the 
uterus,  liver,  intestines,  or  stomach. 

The  following  are  the  principal  characters  of  swell- 
ings involving  the  several  viscera. 

Liiver. — Situation  in  the  epigastrium  and  right 
hypochondrium.  The  swelling  extends  upwards 
beneath  the  ribs  and  is  in  contact  with  them.  The 
anterior  and  upper  surface  is  smooth  and  convex.  The 
lower  border  is  well-defined,  and  there  is  a  notch  in  it 
for  the  round  ligament.     No  intestine  lies  in  front  of  it. 


DISEASES    OF    THE    ABDOMEN.  147 

The  dulness  is  continuous  with  the  normal  liver 
dulness.  The  latter  may  be  extended  upwards  as  well 
as  downwards. 

A  certain  amount  of  downward  displacement,  but 
usually  not  very  much,  may  be  noticed  when  the 
patient  takes  a  deep  breath. 

Gall-bladder. — The  gall-bladder  when  consider- 
ably distended  appears  in  the  form  of  a  globular  smooth 
swelling,  situated  just  below  the  tip  of  the  tenth  right 
costal  cartilage,  or  in  a  line  extending  downwards  from 
this  point  and  slightly  to  the  left.  If  the  lower  edge 
of  the  liver  can  be  felt  in  or  near  this  line  the  rounded 
gall-bladder  will  be  felt  just  below  it. 

The  gall-bladder,  except  in  a  few  cases  in  which  it 
is  enormously  distended,  or  in  which  the  whole  liver  is 
enlarged  or  displaced  downwards,  rarely  extends  below 
the  level  of  the  umbilicus. 

A  distended  gall-bladder  often  has  a  good  deal  of 
lateral  mobility,  but  cannot  be  displaced  downwards 
apart  from  the  liver. 

A  very  large  gall-bladder  can  often  be  felt  bi- 
manually,  one  hand  being  placed  upon  its  fundus,  the 
other  in  the  loin  just  below  the  last  rib.  It  is  this 
palpability  from  the  loin  that  leads  sometimes  to  con- 
fusion between  enlarged  gall-bladder  and  swellings  of 
the  kidney.  Cases  are  by  no  means  unknown  in  which 
incision  has  been  made  upon  the  gall-bladder  from  the 
loin,  under  the  impression  that  it  was  a  kidney  with 
which  the  surgeon  was  dealing. 

A  distended  gall-bladder  almost  alwaj^s  lies  in  contact 
with  the  anterior  abdominal  wall,  and  has  therefore  no 
intestine  in  front  of  it. 

Its   relation   to   the   colon    may   be   determined   if 


148  SURGICAL   DIAGNOSIS. 

necessary  by  inflating  tlie  latter,  which  will  be  found 
to  lie  below  a  gall-bladder,  but  in  front  of  a  swelling  of 
renal  origin. 

From  tumours  springing  from  the  substance  of  the 
liver  the  gall-bladder  can  often  be  distinguished  by  its 
lateral  mobility,  and  by  its  projection  away  from  the 
liver. 

Jaundice,  or  a  history  of  jaundice,  may  help  in  the 
diagnosis  of  distension  of  the  gall-bladder ;  but  it  must 
be  remembered  that  in  most  of  the  cases  in  which  the 
gall-bladder  forms  a  distinct  tumour,  the  cause  of  the 
distension  lies  in  an  obstruction  of  the  cystic  duct,  and 
there  is  consequently  no  associated  jaundice. 

Spleen. — Situation  in  the  left  hypochondrium,  and 
in  a  line  drawn  from  this  downwards  and  somewhat  to 
the  right.  The  swelling  extends  upwards  beneath  the 
ribs  and  is  in  contact  with  them. 

The  anterior  and  outer  surface  is  smooth  and  convex. 
The  inner  and  anterior  border  is  well  defined,  and  at  its 
lower  part  are  one  or  more  well-marked  notches  which 
are  very  characteristic.  No  intestine  lies  in  front  of  it. 
The  dulness  is  continuous  with  the  normal  splenic 
dulness  in  the  mid-axillary  line  opposite  the  ninth, 
tenth,  and  eleventh  ribs. 

Most  of  the  above  characters  can  be  made  out  only 
when  the  spleen  is  much  enlarged,  and  extends  well 
below  the  costal  margin.  In  many  cases  in  which  the 
enlargement  is  not  great,  the  spleen  can  be  felt  only  by 
pressing  the  fingers  deeplyinto  the  hypochondrium  while 
the  patient  takes  a  deep  breath.  The  spleen  is  then  felt 
as  a  rounded  mass  descending  upon  the  fingers. 

Stomach. — The  outline  of  a  distended  stomach  with 
its  convex  lower  border  can  often  be  seen  and  felt  if  the 


DISEASES    OF   THE   ABDOMEN.  149 

abdominal  wall  is  thin  and  the  intestines  not  much  dis- 
tended. These  conditions  are  often  present  in  cases  of 
stricture  of  the  pylorus.  Marked  tympanites  in  the  left 
hypochondrium,  and  the  presence  of  a  bell  sound  on 
auscultation,  may  help  in  the  diagnosis  of  distension  of 
the  stomach.  The  outline  of  a  distended  stomach  is 
made  more  evident  by  inflating  it  *  with  air  through  a 
soft  tube  passed  down  the  oesophagus.  Or  inflation  may 
be  conveniently  effected  in  another  way,  by  allowing  the 
patient  to  swallow  separately  small  quantities  of  water 
containing  thirty  to  forty  grains  of  bicarbonate  of  soda 
and  of  tartaric  acid. 

The  possible  risk  of  causing  perforation  of  a  diseased 
stomach  by  over  distension  should  not  be  forgotten. 

The  diagnosis  in  many  cases  has  to  be  made,  however, 
not  so  much  by  direct  physical  examination  of  the 
stomach  as  by  the  evidence  afforded  by  dyspeptic  symp- 
toms, and  by  the  vomiting  of  large  quantities  of  fluid, 
especially  fluid  of  a  thin  watery  nature.  The  passage 
of  a  tube  into  the  stomach,  and  measuring  its  capacity 
by  the  injection  of  fluid,  is  sometimes  of  service. 

Localised  tumours  of  the  stomach  are  most  character- 
istic when  they  occur,  as  they  so  often  do,  at  the  pylorus. 
In  other  parts  of  the  stomach  they  are  less  easily  felt, 
and  their  signs  are  not  so  distinctive.  The  diagnosis  of 
a  tumour  of  the  stomach,  apart  from  the  pylorus,  is 
made  partly  by  its  situation,  partly  by  its  mobility  with 
varying  degrees  of  distension  of  the  organ,  but  mainly 
by  the  examination  of  the  contents  of  the  stomach,  and 
by  the  general  symptoms. 

*  In  the  absence  of  a  better  instrument,  an  ordinary  bicycle  pump 
will  be  found  serviceable  for  this  purpose. 


150  SURGICAL   DIAGNOSIS. 

Pancreas. — Owing  to  their  deep  situation  at  the 
back  of  the  abdomen,  most  swellings  of  the  pancreas 
have  but  few  physical  signs  of  importance.  A  lump 
in  the  situation  of  the  head  of  the  pancreas,  having 
little  or  no  mobility,  is  generally  all  that  can  be  made 
out  by  physical  examination  of  the  swelling  itself.  The 
common  malignant  disease  of  the  head  of  the  pancreas, 
and  the  chronic  inflammatory  induration  of  the  same 
part  seldom  attain  large  dimensions,  and  present  only  the 
above  characters.  Occasionally  cysts  of  the  pancreas, 
both  unilocular  and  multilocular,  attain  a  large  size,  and 
present  the  characters  of  fluid-containing  tumours 
situated  in  the  upper  left  part  of  the  abdomen.  They 
tend  to  push  the  stomach  forwards  and  upwards,  and 
the  transverse  colon  forwards,  or  forwards  and  down- 
wards. As  has  already  been  mentioned,  such  tumours 
simulate  very  closely  collections  of  fluid  in  the  lesser 
peritoneal  cavity  (see  p.  142). 

The  diagnosis  of  most  tumours  of  the  pancreas,  how- 
ever, depends  less  upon  the  physical  characters  of  the 
swelling  itself  than  upon  the  symptoms  produced  by 
the  involvement  of  certain  neighbouring  structures. 
The  most  important  of  these  are  the  common  bile-duct, 
the  pancreatic  duct  in  the  pancreas  itself,  and  the 
duodenum  surrounding  its  head. 

Any  tumour  in  the  head  of  the  pancreas,  but  especially 
the  common  carcinoma,  will  tend  to  involve  the  common 
bile-duct  by  pressure  or  infiltration,  or  both.  Jaundice 
will  thus  be  produced.  Obstruction  of  the  pancreatic 
duct  is  much  more  difficult  to  detect,  but  the  loss  of 
pancreatic  secretion  may  pei'haps  be  detected  by  the 
presence  of  undigested  fat  in  the  motions. 

The  duodenum,  which  nearly  encircles  the  head  of  the 


DISEASES    OF    THE    AEDOMEX.  I^I 

pancreas,  is  easily  compressed  by  tumours  of  that  organ, 
especially  if  they  are  of  considerable  size  or  enlarge 
rapidly  (as  in  haamorrhage  into  a  cyst).  Under  these 
conditions,  symptoms  of  sub-acute,  or  even  acute, 
intestinal  obstruction  are  easily  induced.  Large  cysts 
of  the  pancreas  are  likely  also  to  press  upon  the 
transverse  colon. 

Kidney. — Situation  in  the  loin.  It  can  be  felt  by 
the  two  hands,  one  of  which  is  placed  at  the  back  below 
the  last  rib,  the  other  on  the  front  of  the  abdomen. 
Karely  the  kidney  lies  further  forward  and  nearer  the 
middle  line,  resting  more  upon  the  lumbar  spine.  In 
these  cases  the  tumour  is  felt  with  difficulty,  or  not  at 
all  from  behind,  but  forms,  on  the  other  hand,  a  swelling 
that  is  more  easily  detected  from  the  front.  The  very 
rare  cases  in  which  the  kidney  occupies  an  altogether 
abnormal  situation,  lying  upon  the  brim  of  the  true 
pelvis,  or  in  front  of  the  last  lumbar  vertebrae,  do  not 
require  any  further  mention. 

It  should  be  remembered  that  the  enlargement  of  one 
kidney  may  be  associated  with  congenital  absence  of  its 
fellow.  The  association  of  hydronephrosis  on  one  side, 
with  congenital  absence  of  kidney  on  the  other,  is  by  no 
means  unknown,  and  is  of  much  practical  importance 
in  connection  with  operations  on  the  former. 

The  shape  of  an  enlarged  kidney  depends  upon 
whether  the  organ  is  enlarged  uniformly,  or  whether  the 
pelvis  is  the  main  seat  of  enlargement. 

The  uniformly  enlarged  kidney  ]3reserves  its  natural 
shape,  being  convex  on  its  outer  border,  concave  on  the 
inner.  Distinct  lobulation  can  often  be  felt  in  kidneys 
that  are  much  enlarged. 

If  the  pelvis  form  the  main  portion  of  the  swelling, 


1^2  SURrrTCAL   DIAGNOSIS. 

as  in  many  cases  of  simple  hyclroneplirosis,  then  a 
globular  swelling  is  the  result.  A  greatly  distended 
renal  pelvis  may  present,  on  its  outer  or  anterior  surface, 
the  remainder  of  the  kidney  perhaps  but  little  altered, 
and  if  this  can  be  felt,  it  is  a  great  help  towards  the 
diagnosis. 

Dulness  in  the  loin  is  characteristic  of  a  renal  swell- 
ing unless  the  latter  occupy  an  altogether  abnormal 
position. 

The  relation  of  the  colon,  if  it  can  be  made  out,  is 
of  the  greatest  importance  in  the  diagnosis  of  a  renal 
swelling. 

If  the  abdominal  wall  be  fairly  thin  and  the  tumour 
sufficiently  laro-e,  the  colon  can  be  felt  as  a  thickened 
band  running  more  or  less  vertically  over  the  surface 
of  the  latter  and  generally  firmly  attached  to  it  by  the 
peritoneum.  The  presence  of  gas  in  this  thickened 
band  helps  to  determine  its  nature.  In  some  cases  it 
is  even  desirable  to  inflate  the  colon  with  air.  Its 
relation  to  the  swelling  is  then  rendered  obvious,  and 
the  renal,  or  at  any  rate  retroperitoneal,  nature  of  the 
tumour  is  placed  beyond  doubt. 

Irregular  swellings  involving  a  part  only  of  the 
kidney  may  present  great  difficulties  in  diagnosis, 
especially  if  they  involve  the  upper  end  of  the  kidney 
and  are  not  very  movable.  Such  are  some  cysts  and 
masses  of  new  growth.  From  their  close  proximity  to 
the  liver,  gall-bladder  and  suprarenal  gland,  they  may 
easily  be  confused  with  swellings  of  these  organs. 

The  suprarenal  gland,  from  its  small  size  and  deep 
situation,  seldom  gives  rise  to  enlargement  which  can 
be  diagnosed  by  direct  physical  examination.  Some 
tumours  however,  both  innocent  and  malignant,  form 


DTSEAftER    OF   THE    ABDOMEN.  1^3 

large  rounded  or  irregular  masses,  which  are  situated 
deeply  in  the  loin  and  resemble  tumours  of  the  upper 
part  of  the  kidney. 

Tuberculous  disease  of  the  suprarenal  is  often 
diagnosed  with  ease,  not  by  the  physical  characters  of 
the  swelling,  but  by  the  presence  of  bronzing  of  the 
skin,  vomiting,  attacks  of  faintness,  and  the  other  well- 
known  symptoms  of  Addison's  disease. 

Bladder. — There  is  seldom  any  difficulty  in  the 
diagnosis  of  a  distended  bladder. 

The  situation  of  this  organ,  in  the  middle  line 
immediately  behind  the  pubes  and  lower  part  of  the 
abdominal  wall,  its  accessibility  to  examination  by 
the  finger  in  the  vagina  or  rectum,  and  by  the  sound 
introduced  per  urethram,  generally  leaves  no  doubt 
as  to  the  nature  of  the  swelling.  Distension  of  the 
bladder  is  occasionally  simulated  by  collections  of 
fluid  (pus,  urine,  or  blood),  and  still  more  rarely  by 
tumours,  in  the  cellular  tissue  in  front  of  the  bladder. 
Occasionally  swellings  behind  the  bladder,  such  as 
enlargements  of  the  uterus,  the  ovary,  or  even  the 
Fallopian  tube  may  resemble  the  bladder  itself. 
Cysts  in  connection  with  the  bladder  itself,  such  as 
pouches  from  the  bladder  and  hydatids  in  the  cellular 
tissue  close  to  it,  will  sometimes  cause  difficulties  in 
diagnosis. 

Large  malignant  tumours  of  the  bladder  filling  up 
the  pelvis  and  rising  out  of  it  sometimes  resemble 
distension  of  the  bladder.  The  emptying  of  the 
bladder  with  the  catheter,  if  this  is  possible,  and 
observation  of  the  extent  to  which  a  catheter  can  be 
passed  and  its  direction,  will  generally  serve  to  obviate 
any   error.      Inability   to   pass   a  catheter  (e.g.,  from 


154  SURGICAL    DIAGNOSIS. 

stricture)  or  an  erroneous  history  as  to  the  complete 
emptying  of  the  bladder  by  micturition,  may  occasionally 
lead  to  error. 

Uterus. — The  situation  of  this  organ  between  the 
bladder  and  upper  part  of  the  rectum,  in  the  pelvis 
or  rising  up  out  of  it,  and  its  accessibility  to  direct 
examination  by  the  hand  upon  the  abdomen,  the  finger 
in  the  vagina  and  the  sound  in  its  interior  (if  it  is 
permissible  to  make  use  of  this),  are  in  most  cases 
sufficient  for  a  diagnosis  as  to  the  uterine  nature  of 
the  swelling.  In  the  case  of  the  pregnant  uterus,  the 
characters  of  the  cervix,  the  state  of  the  breasts  and 
the  other  well-known  signs  of  pregnancy,  afford  material 
help  in  the  diagnosis.  Discharges  from  the  interior 
of  the  uterus  (blood,  pus,  &c.)  also  help  in  many  cases. 

Small  uterine  swellings  are  likely  to  be  confused 
with  swellings  of  the  ovary,  tube,  or  broad  ligament, 
and  with  collections  of  fluid  or  inflammatory  swellings 
in  the  immediate  neighbourhood  of  the  uterus.  Large 
uterine  swellings  rising  up  into  the  abdomen  are  likely 
to  be  confused,  in  the  absence  of  history  or  other 
evidence  of  pregnancy,  with  ovarian  cysts  and  occa- 
sionally with  tumours  of  the  bladder,  intestine,  mesen- 
tery and  retroperitoneal  cellular  tissue. 

The  subject  is  one  however  which  belongs  rather  to 
the  gyn£ecologist  than  to  the  general  surgeon. 

Intestines. — Distension  of  the  intestines  may  of 
course  affect  any  part  of  the  abdomen,  but  usually 
affects  all  parts  nearly  equally,  filling  up  the  whole 
abdomen.  The  shape  of  a  distended  colon  would  in 
itself  be  very  characteristic  were  it  not  for  the  fact 
that  such  distension  is  almost  always  accompanied  and 
obscured  by  the  distension  of  the  small  intestine  above 


DISEASES   OF   THE   ABDOMEN.  155 

ifc.  The  characteristic  shape  of  the  colon  cannot 
therefore  usually  be  felt,  and  it  is  difficult  to  say  how 
much  of  the  distension  is  due  to  colon,  and  how  much 
to  small  intestine.  Careful  palpation,  percussion, 
and  auscultation  will  however  sometimes  enable  the 
situation  of  the  distended  colon  to  be  accurately  traced. 
Distension  of  the  small  intestine  alone,  or  of  a  part  of 
it,  sometimes  permits  of  diagnosis.  A  mass  of  resonant 
intestine  that  can  be  pushed  about  from  side  to  side  in 
an  abdomen  that  is  not  greatly  distended  consists  of 
small  intestine.  Sometimes  numerous  coils  of  intestine 
are  matted  together  by  chronic  inflammation  into 
irregularly  rounded  masses  that  are  freely  movable 
and  not  difficult  to  diagnose.  They  are  especially 
common  in  young  children. 

The  diagnosis  between  general  abdominal  distension 
due  to  the  intestines  and  that  due  to  other  conditions 
has  already  been  discussed. 


CHAPTER  XV. 

ABDOMINAL  PAIN. 

Abdominal  pain  is  often  the  most  prominent  symptom 
of  which  the  patient  makes  complaint.  It  seems  well, 
therefore,  to  devote  a  few  pages  to  its  consideration,  and 
to  discuss  its  value  from  a  diagnostic  point  of  view. 

Abdominal  pain  may  be  merely  a  referred  pain  due 
to  some  irritation  at  the  origin  of,  or  in  the  course  of, 
nerves  which  eventually  reach  the  abdomen.  The  pain 
so  often  felt  in  the  front  of  the  abdomen  in  cases  of 
acute  caries  of  the  lumbar  or  lower  dorsal  spine  is  a 
familiar  example. 

Bearing  in  mind  this  point  then,  that  abdominal  pain 
may  be  due  to  disease  away  from  the  abdomen  itself, 
and  that  the  cause  may  have  to  be  sought  in  disease  of 
the  spine,  we  may  pass  to  pain  which  has  its  origin  in 
the  abdomen. 

In  the  vast  majority  of  cases,  abdominal  pain  origi- 
nates in  disease  of  the  abdomen. 

The  situation  of  the  pain  may  indicate  the  situation 
of  the  disease,  and  generally  does  so.  But  very  often 
the  situation  of  the  pain  does  not  correspond  to  that 
of  the  disease.  The  pain  originating  in  disease  of  one 
part  of  the  abdomen  may  be  felt  chiefly  or  wholly  in 
another. 


ABDOMINAL    PAIN.  1 57 

Thus,  a  stone  in  the  kidney  may  cause  a  pain  which 

is  felt  mainly  or  even  wholly  in  the  testis  ;  the  pain 

caused  by  strangulation  of  a  portion  of  small  intestine 

may  be  felt  at  the  umbilicus  ;  that  of  disease  of  the  liver 

may  be  referred  principally  to  the  shoulder.    In  most  of 

these    cases,   however,  the  pain  is  not   limited  to  the 

distant  part,  but  is  felt  also  at  the  actual  seat  of  disease. 

Indeed,  it  may  be  laid  down  as  a  rough  general  rule, 

which  is  not  without  value,  that  diseases  of  the  kidney 

tend  to  cause  pain  referred  to  the  groin,  testis,  labium, 

or  down  the  thigh ;  diseases  of  the  intestine  tend  to 

cause  pain  referred  to  the  umbilicus ;  while  diseases  of 

the  liver  are  apt  to  produce  pain  in  the  back  and  right 

shoulder.     It  is  common,  too,  for  patients  suffering  from 

painful  affections  of  the  stomach  to  complain  of  pain  in 

the  ''chest"  or  "heart." 

It  is  sometimes  said  that  disease  of  an  organ  on 
one  side  of  the  abdomen  may  cause  pain  to  be  referred 
to  the  opposite  side  of  the  abdomen. 

Thus,  stone  in  one  kidney  has  been  said  to  cause 
pain  simulating  stone  in  the  other  kidney. 

It  may,  however,  be  reasonably  doubted  whether  such 
transference  of  pain  from  one  side  of  the  abdomen  to 
the  other  ever  really  occurs. 

Cases  in  which  such  appears  to  have  been  the  case 
are  probably  instances  either  of  error  on  the  part  of  the 
patient  or  of  the  surgeon,  or  cases  in  which  disease 
existed  on  both  sides  of  the  abdomen. 

It  is  sometimes  said  with  truth  that  the  pain  of 
an  acute  appendicitis  is  felt  more  upon  the  left  side 
than  upon  the  right.  This  is,  however,  not  an 
example  of  transference  of  pain,  but  rather  an  indi- 
cation that  the  peritoneal  inflammation  caused  by  the 


158  SURGICAL    DIAGNOSIS. 

appendicitis  has  spread  across  to  the  left  side.  The 
margin  of  an  area  of  spreading  peritonitis  is  often 
more  painful  than  the  area  in  which  the  inflamma- 
tion had  its  origin,  and  where  it  has  reached  a  later 
and  probably  less  painful  stage. 

Local  abdominal  pain  must  be  taken  to  indicate 
local  disease  at  the  same  spot  only  when  it  is  ac- 
companied by  local  physical  signs.  Of  these  the  most 
important  is  tenderness  or  pain  on  pressure.  Another 
valuable  indication  of  local  disease  within  the  abdomen 
is  the  contraction  of  the  abdominal  muscles,  the  resist- 
ance to  deep  palpation,  so  common  a  sign  of  local 
inflammatory  disease. 

The  character  of  abdominal  pain  naturally  varies 
widely.  There  may  be  every  degree,  from  slight  pain 
amounting  to  little  more  than  discomfort,  up  to  the 
most  severe  and  excruciating  agony.  The  pain  may  be 
constant  or  intermittent. 

Pain  occurring  every  evening  suggests  suppuration. 

Almost  any  disease  of  the  abdomen  may  cause  some 
pain  at  one  time  or  another.  The  mere  weight  of  an  other- 
wise harmless  swelling  may  cause  a  dragging  pain  ;  so 
may  adhesions.  A  very  slight  amount  of  inflammation  in 
any  part  of  the  abdomen  may  lead  to  more  or  less  pain. 

We  are  concerned  here,  however,  not  so  much  with 
the  slighter  forms  of  pain  which  are  in  themselves  not 
usually  characteristic,  but  ratlier  with  those  severe  forms 
in  which  the  pain  is  the  most  prominent  feature  of  the 
case. 

Pain  is  due  either  to  tension  or  to  inflammation.  In 
a  sense  we  may  say  that  all  pain  is  due  to  tension,  since 
even  the  pain  of  inflammation  is  due  to  the  tension  of 
inflammatory  products  acting  upon  minute  nerves. 


ABDOMINAL    PAIN.  159 

Severe  abdominal  pain,  however,  such  as  renal 
colic,  may  occur  independently  of  inflammation. 
Although  painful  inflammation  cannot  really  occur 
without  tension,  yet  tension  may  occur  without  inflam- 
mation and  may  be  the  cause  of  most  severe  pain. 
Ordinary  renal  colic  is  a  good  instance  of  the  latter. 
For  practical  purposes  then  it  is  useful  to  remember 
that  severe  abdominal  pain  is  usually  due  either  to 
acute  inflammation  or  to  tension  without  inflammation. 
Frequently  the  two  are  associated,  as  in  the  painful 
distension  of  an  inflamed  organ. 

A  sudden  and  severe  Attack  of  Abdominal 

Pain 

generally  indicates  one  or  other  of  three  conditions : 

1.  It  may  indicate  colic,  either  intestinal,  biliary, 
or  renal. 

2.  It  may  be  due  to  the  rapid  onset  of  acute  peri- 
tonitis ;  this,  in  many  cases,  is  of  the  form  known  as 
perforative  peritonitis. 

3.  It  may  be  caused  by  acute  strangulation  of  the 
intestine  (or,  rarely,  of  some  other  abdominal  viscus). 

Each  of  these  may  be  accompanied  by  vomiting  and 
by  collapse. 

There  are,  however,  many  points  of  difference  in  the 
sj^mptoms  of  the  various  conditions. 

I.  Colic.     (Intestinal,  biliary,  or  renal.) 

The  term  colic,  although  originally  derived  from, 
and  referring,  to  an  affection  of  the  colon,  has  now  no 
such  restricted  meaning.  It  ma^r  be  used  for  any 
abdominal  pain  of  a  spasmodic  or  paroxysmal  nature. 

Colicky  pain  is  due  essentially  to  spasm  of  involun- 


l6o  SURGICAL   DIAGNOSIS. 

tary  muscles,  and  the  tension  (generally  distension)  of 
the  affected  part.  In  intestinal  colic  it  is  the  contrac- 
tion of  the  involuntary  circular  muscular  fibres  that 
causes  the  pain.  The  pain  may  be  compared  to  that  of 
the  contraction  of  the  voluntary  muscles  in  tetanus. 
The  part  of  intestine  affected  may  be  distended  or  not. 
In  biliary  colic  it  is  the  spasmodic  contraction  of  the 
muscular  fibres  of  the  distended  gall-bladder  (rarely  the 
gall-duct)  that  causes  the  pain.  In  renal  colic  it  is  the 
distension  of  the  kidney  caused  by  blocking  of  the 
ureter  that  is  the  cause  of  pain.  It  is  scarcely  neces- 
sary to  say  that  the  pain  of  biliary  and  renal  colic  is 
not  due  to  the  scraping  of  a  stone  along  the  duct.  The 
stone  is  fixed  when  the  colic  is  at  its  height. 

The  symptoms  of  renal  colic,  too,  are  not  invariably 
due  to  a  hard  substance  like  a  calculus.  They  may  be 
caused  equally  well  by  a  soft  blood  clot  or  a,Bjthmg 
else  that  completely  and  suddenly  blocks  the  ureter 
and  causes  urine  to  distend  the  kidney  behind  the 
obstruction. 

Tenderness  may  be  present  with  colic,  but  it  is  not  a 
marked  feature,  and  may  be  completely  absent.  More 
than  this,  local  pressure  frequently  relieves  the  pain  of 
a  mere  colic,  and  often  serves  to  distinguish  between 
colic  and  the  pain  that  is  due  to  acute  inflammatory 
disease.  In  biliary  and  renal  colic,  in  which  there  is  a 
distended,  and,  perhaps,  also  a  somewhat  inflamed  gall- 
bladder, or  kidney,  local  tenderness  may  be  sufiiciently 
marked.  In  all  forms  of  colic  the  early  history  of  the 
case  and  the  presence  of  symptoms  pointing  definitely, 
either  in  the  present  or  in  the  past,  to  disease  of  the 
intestine,  kidney,  or  biliary  passages  may  help  in  the 
diagnosis. 


ABDOMINAL    PAIN.  l6l 

A  normal  temperature  in  cases  of  mere  colic,  although 
by  no  means  sufficient  to  exclude  inflammatory  disease, 
also  helps  in  the  diagnosis. 

2.  Acute  peritonitis. 

Here  pain  is  a  very  variable  symptom,  and  is  no 
criterion  of  the  severity  or  seriousness  of  the  disease. 

In  the  earlier  stages  of  the  disease  it  is  due  to  the 
inflammation  of  the  peritoneum  itself ;  in  the  later 
stages,  spasm  of  muscles,  distension  of  intestines,  and 
the  tension  due  to  accumulation  of  inflammatory  pro- 
ducts, play  their  part  in  the  production  of  pain. 
Sudden  acute  peritonitis  is  due  to  the  entrance  of 
septic  material  into  the  peritoneal  cavity,  and  to  the 
irritation  caused  thereby. 

This  introduction  of  septic  matter  is  caused  almost 
invariably  by  the  perforation  of  one  of  the  hollow 
viscera  or  by  the  rupture  of  an  abscess.  Septic  matter 
may  also  pass  through  the  wall  of  a  viscus  and  set  up 
peritonitis  without  the  production  of  a  ^'  visible  perfora- 
tion." In  these  cases  the  onset  is  generally  less  sudden 
and  acute.  A  healthy  viscus  will  not  allow  the  trans- 
mission of  bacteria  through  its  wall,  but  if  the  latter 
be  inflamed,  paralysed  by  over  distension,  or  otherwise 
diseased,  then  such  transmission  may  occur.  It  is  in 
this  way  that  peritonitis  may  be  set  up  around  a 
strangulated  piece  of  bowel,  or  in  the  neighbourhood 
of  an  inflamed,  although  not  necessarily  perforated, 
appendix. 

The  amount  of  septic  matter  which  is  suddenty 
extravasated  into  the  peritoneal  cavity  does  not  bear  any 
definite  relation  to  the  amount  of  pain  produced.  It 
does  bear  a  definite  relation  as  a  rule  to  the  symptoms 
of  shock,  and  of  the  subsequent  peritoneal  absorption 


1 62  SURGICAL   DIAGNOSIS. 

which  takes  place.  A  very  small  quantity  of  septic 
matter  extravasated  from  a  perforated  stomach  or 
appendix,  may  cause  a  most  violent  pain,  especially  in 
young  people.  On  the  other  hand,  the  sudden  bursting 
of  a  large  abscess  or  the  sudden  perforation  of  a  dis- 
tended c^cum,  although  usually  painful,  may  be  almost 
unattended  with  pain  ;  the  symptoms  of  shock  are  those 
which  predominate  in  such  cases.  It  is  in  old  people 
especially  that  peritonitis  without  pain  is  most  likely  to 
occur,  and  care  should  be  taken  in  such  cases  that  the 
absence  of  pain  should  not  lead  to  the  erroneous  conclu- 
sion that  peritonitis  cannot  be  present. 

The  nature  of  the  extravasated  fluid  is  of  more 
importance  in  the  production  of  pain.  The  extremely 
irritating  contents  of  the  stomach  and  small  intestine 
are  likely  to  cause  excessive  pain.  Comparatively 
unirritating  fluids,  like  healthy  bile  and  healthy  urine, 
may  cause  but  little  pain. 

It  should  ever  be  borne  in  mind  that  the  seriousness 
of  peritonitis,  as  regards  the  life  of  the  patient,  depends 
not  upon  the  intensity  of  the  local  inflammation,  but 
upon  the  absorption  of  septic  matter  that  takes  place. 
Death  from  ^'  peritonitis  "  is  not  due  to  the  inflammation 
of  the  peritoneum,  but  to  the  absorption  of  septic 
matter  that  takes  place  so  readily  from  the  peritoneal 
cavity,  itself  a  vast  lymphatic  space. 

Indeed,  peritonitis  in  itself  should  rather  be  regarded 
as  protective  and  beneficial,  in  that  it  tends  in  many 
cases  to  limit  and  prevent  that  absorption.  The  abun- 
dant exudation  of  sticky  lymph  that  exudes  from  an 
inflamed  peritoneal  surface  tends  to  check  absorption 
by  interposing  a  barrier  between  the  septic  matter  and 
the  general  lymphatic  and  circulatory  systems. 


Abdominal  pain.  163 

The  most  valuable  clinical  indication  of  absorption 
from  the  peritoneum  is  a  rapid  and  increasing  pulse  rate. 
Elevation  of  temperature  is,  in  the  early  stages  at  least, 
much  less  important.  A  fall  of  temperature  is  gener- 
ally the  first  efi*ect  of  sudden  and  extensive  peritoneal 
absorption  ;  later  on,  the  temperature  may  rise  above 
normal  and  to  a  great  height,  as  the  general  blood 
poisoning  becomes  more  marked.  But  in  some  of  the 
worst  and  most  rapid  cases  the  temperature  never 
reaches  the  normal. 

The  diagnosis  of  a  perforative  peritonitis  having 
been  made  in  any  given  case,  the  next  point  to  consider 
is  the  seat  of  the  perforation. 

In  endeavouring  to  answer  this,  which  is  often  a 
very  difficult  question,  we  may  consider,  more  or  less 
separately^  four  points. 

(a)  General  conditions  as  to  age  and  sex. — In 
children  and  young  adults  generally,  appendicitis  is 
the  most  frequent  cause  of  perforative  peritonitis.  It  is 
much  less  commonly  the  cause  in  people  who  have 
passed  middle  life. 

In  young  women  perforation  of  a  gastric  ulcer  is 
common.  The  possibility  of  a  perforation  having  its 
origin  in  inflammatory  disease  of  the  pelvic  organs 
should  not  be  ignored. 

A  duodenal  ulcer  may  occur  at  any  age,  but  is,  per- 
haps, especially  common  in  young  men. 

Beyond  middle  life  the  possibility  of  perforation  of 
the  gall-bladder  becomes  more  probable,  as  does  also 
that  due  to  malignant  disease  of  stomach,  intestine,  or 
other  part. 

(5)  Previous  history  of  the  case,  with  special  refer- 
ence to  symptoms  pointing  to  disease  of  any  particular 


164  SUBGTCAL   DIAGNOSIS. 

organ. — A  young  woman  with  symptoms  of  dyspepsia 
and  angemia  will  naturally  suggest  gastric  ulcer :  a 
young  man  with  the  same  symptoms  is  not  unlikely 
to  have  duodenal  ulcer.  It  is  very  important,  never- 
theless, to  remember  that  conclusion  must  not  be 
too  hurriedly  formed  on  these  grounds  alone.  Many 
an  abdomen  has  been  opened  for  supposed  perforated 
ulcer  of  the  stomach,  and  appendicitis  has  subsequently 
been  found.  (The  converse  mistake,  too,  is  one  that 
has  often  been  made.) 

Many  patients  with  appendicitis  give  a  history  of 
chronic  dyspepsia,  and  anaemia  is  often  one  of  their 
characteristics.  A  history  of  chronic  constipation, 
with  occasional  attacks  of  diarrhoea  and  attacks  of  sick 
head-ache,  will  point  to  appendicitis.  Biliousness, 
hepatic  pain,  perhaps  even  jaundice,  may  point, 
especially  in  elderly  persons,  to  perforation  of  a  gall- 
bladder. Perforation  of  a  gall-bladder  is,  however, 
not  common. 

A  history  of  chronic  and  severe  intestinal  obstruction 
culminating  in  sudden  peritonitis  suggests  perforation 
of  the  bowel.  This  usually  takes  place  at  the  caecum, 
but  may  occur  at  the  seat  of  obstruction.  It  is  obvious 
that  if  the  patient  develops  symptoms  of  perforative 
peritonitis  in  the  course  of,  or  during  convalescence 
froQi,  typhoid  fever,  it  is  probable  that  a  typhoid  ulcer 
is  the  cause. 

(c)  Exact  situation  of  the  pain  at  the  onset  of  the 
attack. — Patients  suffering  from  perforation  of  an 
organ  at  the  upper  part  of  the  abdomen,  e.g.,  the 
stomach,  often  refer  this  pain  to  the  whole  abdomen 
or  to  the  lower  part  of  it.  This  generally  means  that 
the  extravasated  fluid  has  gravitated  downwards.     This 


ABDOMINAL    PAIN;  1 65 

low  situation  of  the  pain  is  likel}^  to  cause  serious  error 
in  diagnosis.  Such  error  may,  however,  generally  be 
avoided  if  care  is  taken  to  ascertain  the  situation  of  the 
pain  at  the  very  beginning  of  the  attack  ;  at  this  early 
stage  it  will  probably  have  been  felt  at  the  seat  of 
perforation. 

Conversely,  perforation  of  the  appendix  may  cause 
pain  all  over  the  abdomen,  or  even  at  the  upper  part, 
but  the  latter  is  very  rare. 

The  position  that  the  patient  has  assumed  has  natu- 
rally some  influence  on  the  situation  of  the  pain.  If 
the  patient  keeps  the  upright  position,  extravasated 
material  tends  to  fall  by  gravity  towards  the  lower  part 
of  the  abdomen.  A  patient  who  keeps  strictly  to  the 
recumbent  position  has  a  better  chance  of  keeping  the 
extravasated  material  localised  to  the  neighbourhood  of 
the  perforation. 

A¥ith  a  clear  and  distinct  history  of  localised  pain  at 
the  beginning  of  an  attack  of  perforative  peritonitis,  it 
may  be  concluded,  in  the  absence  of  other  evidence, 
that  pain  at  the  upper  part  of  the  abdomen  probably 
means  perforation  of  stomach,  duodenum,  or  gall- 
bladder ;  pain  beginning  at  the  lower  part  of  the  ab- 
domen, either  perforation  of  some  pelvic  abscess  or  of 
the  appendix ;  appendicitis  being  still  more  likely  if 
the  pain  be  distinctly  in  the  right  iliac  fossa. 

(d)  Local  physical  signs,  such  as  the  presence  of  a 
definite  area  of  tenderness,  of  muscular  resistance,  of 
dulness,  or  even  of  a  tumour,  may  afford  material  help 
in  the  diagnosis.  Frequently,  however,  when  the  case 
is  first  seen,  there  is  so  much  general  distension  of  the 
abdomen  that  physical  examination  does  not  throw  much 
light  upon  the  seat  of  the  perforation. 


1 66  SURGICAL   DIAGNOSIS. 

3.  Acute  strangulation  of  intestine. 

This  condition  is  less  common  than  either  of  the  two 
preceding.  The  pain,  although  often  present,  is  not 
usually  very  severe  in  the  early  stages.  At  first  it  is 
rather  of  a  dragging  nature  and  is  generally  referred  to 
the  umbilicus.  If  the  strangulation  be  a  hernial  ring 
there  may  be  local  pain  at  that  part. 

Later,  colicky  pains  set  in,  due  to  the  contraction  of 
the  muscular  fibres  in  the  distended  portion  of  intestine 
above  the  obstruction. 

Later  still,  the  strangulated  portion  of  intestine  sets 
up  peritonitis,  and  the  symptoms  and  signs  are  gradually 
merged  in  those  of  peritonitis. 

The  great  and  characteristic  symptom  which  serves 
chiefly  to  distinguish  acute  obstruction  from  the  other 
causes  of  abdominal  pain  is  the  violent  and  frequent 
vomiting.  Vomiting,  as  has  already  been  mentioned, 
is  a  common  symptom  both  of  some  forms  of  simple 
colic  and  of  peritonitis,  but  in  these  cases  it  is  almost 
always  much  less  severe  and  violent.  Some  forms  of 
irritant  poisoning  may  simulate  intestinal  obstruction, 
but  are  generally  distinguishable  by  careful  attention 
to  the  history  and  by  the  special  signs  that  they  may 
present.  Tenderness  is  not  a  marked  feature  of  intes- 
tinal strangulation  before  peritonitis  has  set  in.  Nor 
does  the  pulse  show  that  tendency  to  rapid  increase 
which  is  so  characteristic  of  acute  peritonitis. 

The  same  may  be  said  of  constipation,  which  is 
always  complete  and  absolute  in  intestinal  strangula- 
tion, but  often  less  marked  in  inflammatory  conditions 
of  the  abdomen,  and  still  less  so  in  cases  of  mere  colic. 
In  both  of  these  conditions  flatns  may  be  passed  even 
when  there  is  no  evacuation  of  solid  matter. 


CHAPTER   XVI. 

INTESTINAL    OBSTRUCTION. 

When  the  surgeon  is  called  to  a  case  of  supposed  intes- 
tinal obstruction  he  will  do  well  to  ask  himself  first  of 
all  whether  the  case  is  really  one  of  true  mechanical  ob- 
struction ;  whether,  if  acute,  it  may  not  be  rather  one  of 
those  numerous  cases  of  inflammatory  disease  of  the 
abdomen  (appendicitis,  peritonitis,  enteritis,  &c.) 
which  so  often  and  so  closely  simulate  true  mechanical 
obstruction. 

The  diagnosis  is  to  be  made  chiefly  by  careful  atten- 
tion to  the  early  history  of  the  case,  and  to  the  nature 
and  urgency  of  the  vomiting.  He  must  endeavour  to 
separate  the  symptoms  of  inflammation  from  those  of 
obstruction,  and  assign  their  relative  value  to  each.  The 
difiiculty  of  diagnosing  between  inflammatory  conditions 
and  conditions  of  mechanical  obstruction  is  naturally 
increased  by  the  fact  that  intestinal  obstruction  sooner 
or  later  is  complicated  by  such  inflammatory  conditions* 
To  the  symptoms  of  obstruction  are  superadded  those 
of  peritonitis.  Similarly  in  some  cases  which  began  as 
simple  inflammation  without  obstruction,  such  as  appen- 
dicitis or  peritonitis,  the  symptoms  of  obstruction 
become  added  to  those  of  inflammation.  For  example, 
an  abscess  of  the  appendix  may  press  upon  the  ileum  so 
as  to  cause  a  mechanical  obstruction ;  or  an  inflammatory 


1 68  SURGICAL    DIAGNOSIS. 

band  of  adhesions  may  produce  a  similar  effect ;  or  the 
inflamed  and  distended  intestine  may  become  go  para- 
l3^sed  as  to  be  incapable  of  contracting,  and  thus  acts  as  an 
obstruction.  If  the  case  be  a  chronic  one  without  urgent 
symptoms,  the  question  will  arise  whether  there  is  an 
actual  mechanical  obstruction,  or  whether  the  case  is 
merely  one  of  obstinate  constipation.  A  gradual  narrow- 
ing of  the  intestine,  from  the  presence  of  a  new  growth 
or  the  contraction  of  an  ulcer,  may  cause  practically  no 
prominent  symptoms  at  all  bej'ond  constipation,  and 
diagnosis  is  consequently  difficult.  In  the  absence  of 
more  definite  evidence  of  an  obstruction,  the  amount  of 
tension  in  the  abdomen  is  the  best  guide. 

Given  that  there  is  reasonable  evidence  of  true  me- 
chanical obstruction,  the  next  points  are  to  determine 
if  possible  the  nature  and  seat  of  the  obstruction.  In 
endeavouring  to  determine  these  two  points,  we  have 
to  consider — 

1.  Evidence  from  the  age,  sex,  and  general  habits  of 
the  patient. 

2.  Evidence  from  the  previous  history  of  the  patient. 

3.  Evidence  from  the  symptoms  actually  present  at 
the  time. 

4.  Evidence  from  physical  examination  of  the  patient. 

I.  Age,  sex,  and  general  habits  of  the 
patient. 

Age  alone  is  sometimes  a  valuable  aid  to  the  diagnosis. 
Symptoms  of  acute  obstruction  in  a  young  infant  would, 
in  the  absence  of  any  contra  indication,  point  strongly 
towards  intussusception,  since  no  other  form  of  acute 
obstruction  (other  than  congenital  obstructions  at  and 
immediately  after  birth)  are  at  all  common  at  this  age. 


INTESTINAL    OBSTEUCTTON.  I  69 

The  diagnosis  of  intussusception  can  usually  be  easily- 
confirmed  by  careful  physical  examination.  In  chil- 
dren who  are  no  longer  infants  acute  obstruction  is 
likely  to  be  due  to  bands  of  adhesion  caused  by  previous 
inflammatory  disease  of  the  abdomen.  Bands  of  adhe- 
sion due  to  old  appendicitis  are  common  ;  so  are  those 
connected  with  inflamed  and  suppurating  tuberculous 
glands  in  the  mesentery.  Congenital  bands,  associated 
or  not  with  Meckel's  diverticulum,  are  also  not  to  be 
ignored  at  this  age. 

In  adult  life,  and  at  any  point  of  it,  the  various  forms 
of  hernia,  both  internal  and  external,  become  common, 
as  also  obstruction  due  to  twists  and  kinks  of  small 
intestine.  Beyond  middle  life  obstruction  due  to  malig- 
nant disease  becomes  frequent ;  much  less  common,  and 
occurring  almost  exclusively  in  advanced  life,  is  obstruc- 
tion from  gall-stones. 

Consideration  of  the  age  of  the  patient,  however, 
does  little  more  than  suggest  a  probable  cause  for  the 
obstruction.  The  actual  diagnosis  depends  upon  history, 
symptoms,  and  physical  examination. 

Inflammatory  conditions  of  the  pelvic  organs  are  of 
course  common  in  women.  These  may  lead  to  adhesions 
which  in  their  turn  are  fertile  sources  of  intestinal 
obstruction  in  this  sex. 

Habits  of  life. — But  little  need  be  said  under  this 
heading.  Elderly  people  of  sedentary  habits  are  those 
in  whom  obstruction  by  gall-stones,  and  the  chronic 
obstruction  due  to  impacted  faeces,  are  most  likely  to 
occur. 

Long-continued  neglect  of  the  bowels  may  have  some 
share  in  the  production  of  a  volvulus,  and  certainly 
contributes  to  faecal  impaction. 


170  SURGICAL    DIAGNOSIS. 

2.  Previous  history. 

Careful  inquiry  should  be  made  about  the  previous 
history  as  regards  any  injury  or  disease  of  the  abdomen, 
or  any  abdominal  symptom  that  may  throw  light  on  the 
cause  of  the  obstruction.  A  history  of  previous  peritonitis 
or  other  acute  inflammatory  affection  would  suggest  the 
presence  of  bands  of  adhesion  causing  strangulation  or 
kinking  of  the  intestine.  A  history  of  a  severe  abdo- 
minal injury,  or  an  operation  on  the  interior  of  the  abdo- 
men, may  give  a  similar  clue.  A  history  of  long-con- 
tinued diarrhoea  may  suggest  intestinal  ulceration  lead- 
ing to  stricture  ;  a  history  of  dysentery,  or  even  of  resi- 
dence in  a  tropical  climate,  may  suggest  cicatricial  stric- 
ture. A  history  of  typhoid  fever,  however,  can  scarcely  be 
taken  as  pointing  towards  stricture,  since  it  is  well  known 
that  typhoid  ulceration  very  rarely  leads  to  stricture. 

Particular  attention  should  naturally  be  paid  to  the 
manner  in  which  the  intestinal  functions  have  been  per- 
formed, and  especially  to  a  history  of  long-continued 
constipation.  A  history  of  long-continued  constipation 
with  occasional  attacks  of  complete  obstruction  would 
suggest  a  volvulus  of  the  sigmoid  flexure.  Inquiry  should 
also  be  made  as  to  the  previous  existence  of  a  hernia. 

3.  Symptoms. 

The  two  prominent  symptoms  of  intestinal  obstruc- 
tion are  vomiting  and  constipation. 

With  regard  to  the  vomiting,  it  may  be  stated  that 
as  a  general  rule  it  is  most  urgent  and  sets  in  earliest 
in  those  cases  in  which  the  obstruction  is  high  up.  To 
a  certain  extent  the  acuteness  of  the  obstruction  also 
determines  the  severity  of  the  vomiting.  Sudden  and 
complete  strangulation  of  the  small  intestine  causes 
immediate  and  violent  vomiting. 


INTESTINAL    OBSTRUCTION.  171 

In  a  case  of  gradual  closure  of  the  large  intestine  by 
a  malignant  growth,  the  vomiting  may,  on  the  other 
hand,  be  delayed  for  weeks.  It  may  not  set  in  until 
long  after  other  signs  of  obstruction,  such  as  constipation 
and  abdominal  distension,  have  become  very  marked. 

As  extreme  examples  may  be  mentioned  the  two 
following  cases  that  came  under  my  own  observation  : 

One  was  that  of  a  young  man  with  acute  strangula- 
tion of  many  feet  of  small  intestine,  who  was  already 
moribund  within  a  few  hours  of  the  first  onset  of 
symptoms. 

The  other  was  that  of  a  middle-aged  man  with  a 
carcinomatous  stricture  of  the  large  intestine,  who  had 
suffered  for  no  less  than  five  weeks  with  absolute  con- 
stipation, and  who,  nevertheless,  appeared  to  be  in  good 
health,  was  not  vomiting,  was  able  to  get  about,  and 
who  complained  of  nothing  except  the  constipation  and 
great  distension  of  the  abdomen. 

Acute  obstruction  is  most  common  in  the  small  intes- 
tine ;  chronic  obstruction  usually  has  its  seat  in  the 
large  intestine.  It  should  be  remembered  that  a  chronic 
obstruction  may  suddenly  become  acute  at  any  time. 
This  will  mean,  if  the  obstruction  is  high  up,  that  a 
partial  obstruction  of  the  intestine  has  become  complete, 
as  by  the  blocking  of  a  stricture  with  a  lump  of  intestinal 
contents.  The  occurrence  of  acute  symptoms,  however, 
in  a  case  of  chronic  obstruction,  wherever  its  situation, 
mor'e  often  means  the  supervention  of  inflammatory 
symptoms,  such  as  peritonitis,  due  to  rupture  of  the 
serous  coat  of  the  intestine,  or  to  gangrene  or  perfora- 
tion of  the  intestine.  The  early  occurrence  of  vomiting 
in  a  case  of  intestinal  obstruction  is  favoured  by  attempts 
to  take  food. 


172  SURGICAL    DIAGNOSIS. 

The  nature  of  the  vomited  matter  does  not  usually 
afford  material  help  in  the  diagnosis.  In  all  forms  of 
obstruction  the  vomited  matters  tend  at  the  later  stages 
of  the  affection  to  become  foul  and  ill-smelling.  It  is 
in  cases  of  obstraction  of  the  large  intestine  that  the 
vomited  matters  are  truly  fseculent,  and  have  the  foulest 
smell. 

Constipation  in  every  case  of  complete  obstruction 
is,  of  course,  complete  and  absolute.  Nothing  passes 
through  the  obstructed  portion  of  gut ;  nothing,  there- 
fore, can  be  passed  from  the  rectum  except  what  may 
happen  to  have  been  in  the  rectum  or  bowel  below  the 
obstruction.  Even  this  is  not  usually  expelled.  One, 
or  even  more,  evacuations  of  such  contents  may  take 
place,  or  these  contents  may,  to  a  certain  extent,  be 
washed  away  by  enemata.  Even  flatus  is  not  usually 
expelled  in  a  case  of  genuine  obstruction.  Constipation, 
being  a  symptom  which  requires  time  before  it  can 
show  itself,  is  not  of  much  value  in  the  diagnosis  of  the 
early  stages  of  acute  obstruction. 

In  cases  in  which  the  obstruction  has  lasted  more 
than  a  day  or  two,  constipation  becomes  a  symptom  of 
importance. 

Discharges  of  blood  and  mucus  from  the  anus  do 
not  militate  against  the  presence  of  an  obstruction.  On 
the  contrary,  they  often  afford  material  evidence  of  the 
nature  of  the  obstructiou.  Blood  and  mucus  afford 
an  early  and  characteristic  symptom  of  intussusception, 
since  the  strangulated  and  congested  portion  of  intes- 
tine lies  within  the  lumen  of  the  bowel  below  the 
obstruction,  and  hence  discharges  from  it  are  free  to 
find  their  way  out  through  the  anus. 

Intussusception  in  a  young  child  is  most  likely  to  be 


INTESTINAL    OBSTRUCTION.  173 

confused  with  simple  diarrhoea  and  vomiting  due  to 
some  error  in  diet,  or  to  intestinal  tuberculous  ulcera- 
tion. In  the  latter  case,  the  resemblance  to  intussus- 
ception may  be  very  close,  since  the  ulceration  may  lead 
to  the  presence  of  blood  and  slime  in  the  motions,  while 
enlargement  of  mesenteric  glands  connected  with  the 
intestinal  ulceration  may  form  a  swelling  that  can 
easily  be  mistaken  for  an  intussuscepted  portion  of 
bowel. 

In  cases  of  stricture,  malignant  or  otherwise,  accom- 
panied by  much  ulceration,  discharge  of  blood  and 
mucus  may  occur,  but  is  rarely  a  prominent  symptom. 

In  the  majority  of  cases  of  malignant  stricture  of  the 
large  intestine,  at  least  above  the  rectum,  bleeding  is 
not  a  marked  feature. 

In  the  very  rare  cases  of  large  polypi  obstructing  the 
bowel,  there  may  be  a  discharge  of  blood  and  mucus, 
and  the  same  may  be  said  of  the  equally  rare  cases  of 
foreign  bodies  causing  obstruction.  The  foreign  body 
causes  inflammation  of  the  wall  of  the  intestine,  and 
this  inflammation  gives  rise  to  the  discharge  of  mucus, 
and  perhaps  of  blood. 

The  subject  of  pain  in  connection  with  intestinal 
obstruction  has  already  been  discussed  on  page   166. 

4.  Physical  examination. 

Direct  examination  of  the  seat  of  obstruction  may  be 
attempted  from  the  rectum  or  from  the  front  of  the 
abdomen.  The  importance  of  a  careful  and  thorough 
examination  in  both  of  these  ways  is  obvious. 

Examination  by  the  rectum  will  reveal  at  once  the 
presence  of  any  stricture,  malignant  or  otherwise,  at  the 
anus  or  in  the  lower  part  of  the  rectum  ;  that  is,  the 
part  within  reach  of  the  examining  finger.     Stricture 


174  SURGICAL   DIAGNOSIS. 

higher  up  may  also  be  detected  sometimes  by  a  careful 
examination  and  especially  by  bimanual  examination. 
A  malignant  stricture  of  the  sigmoid  flexure  or  upper 
part  of  the  rectum  sometimes  falls  down  into  the  pelvis 
in  such  a  way  that  it  can  be  felt  through  the  wall  of 
the  rectum. 

An  intussusception  not  uncommonly  descends  so  low 
that  it  can  be  felt  in  the  rectum,  or  it  may  even  protrude 
from  the  anus.  The  slight  depression  that  can  be  felt 
near  the  apex  of  the  intussusception,  and  which  is  the 
entrance  to  the  lumen  of  the  bowel  above,  forms  the 
most  reliable  means  of  distinguishing  between  an  intus- 
susception and  a  polypus.  In  the  case  of  an  intus- 
susception that  has  descended  as  low  as  the  rectum  the 
other  symptoms  are  usually  so  characteristic  that  there 
is  but  little  probability  that  any  difficulty  in  the 
diagnosis  will  occur.  Pelvic  tumours  and  bands  of 
adhesion,  &c.,  in  the  pelvis  may  be  felt  and  may  throw 
light  on  the  cause  of  obstruction.  Careful  bimanual 
examination  may  lead  to  the  detection  of  an  obturator 
or  femoral  hernia,  especially  if  the  abdomen  be  not 
very  tense,  so  that  the  external  examining  hand  can 
be  pressed  well  down  towards  the  pelvis.  The  im- 
portance of  a  vaginal  examination  in  women  need  only 
be  mentioned. 

In  the  great  majority  of  cases  of  acute  obstruction, 
rectal  examination  reveals  nothing  more  than  a  general 
bulging  downwards  of  the  abdominal  viscera,  and  no 
light  is  thrown  on  the  cause  of  the  obstruction. 

Attempts  to  examine  the  upper  part  of  the  rectum 
by  the  introduction  of  the  whole  hand  are  of  no  real 
value.  Examination  by  a  bougie  may  help  in  the 
detection  of  a  stricture  that  is  just  beyond  the  reach  of 


INTESTINAL   OBSTRUCTION.  1 75 

the    finger,  but   is  of    no   use    for   the    detection    of 
obstruction  much  above  this. 

Attempts  are  sometimes  made  to  ascertain  the 
situation  of  an  obstruction  by  determining  the  amount 
of  fluid  that  can  be  injected  into  the  lower  bowel. 
Such  attempts  seldom  lead  to  conclusions  of  any  value. 
The  rectum  itself  may  hold  a  considerable  quantity  of 
water  when  the  obstruction  is  as  low  down  as  the 
sigmoid  flexure.  On  the  other  hand  it  may  happen 
when  the  obstruction  is  as  high  as  the  small  intestine 
that  the  amount  of  intra-abdominal  tension  is  never- 
theless so  great  that  not  more  than  a  few  ounces  can 
be  injected  into  the  large  intestine.  The  forcible 
injection  of  fluid  into  the  large  intestine  in  cases  of 
intestinal  obstruction  is  not  without  risk  of  causing 
serious  harm  by  producing  perforation,  &c. 

Abdominal  palpation  in  most  cases  of  intestinal 
obstruction  reveals  little  except  general  distension  of 
the  abdomen. 

The  possibility  of  the  obstruction  being  due  to 
external  hernia  should  never  be  forgotten,  and  careful 
examination  of  the  various  hernial  apertures  should 
always  be  made. 

If  an  external  hernia  be  present,  it  must  not  be  too 
readily  concluded  that  this  is  necessarily  the  cause  of 
the  obstruction.  If  the  local  signs  of  a  strangulated 
hernia  (tension  and  want  of  impulse)  are  not  present 
it  may  be  suspected  that  the  cause  of  the  obstruction 
is  to  be  sought  elsewhere.  A  patient  with  a  reducible 
or  even  an  irreducible  hernia  may  be  the  subject  of  a 
strangulated  hernia  in  some  other  and  less  obvious 
situation,  or  even  of  an  obstruction  due  to  some  wholly 
difierent  cause. 


176  SURGICAL   DIAGNOSIS. 

It  is  in  the  early  stages  of  obstruction,  and  in  cases 
in  which  the  abdominal  wall  is  not  much  distended 
and  not  very  tense,  that  abdominal  palpation  is  likely 
to  afford  most  help. 

In  young  children  especially,  in  whom  the  abdominal 
wall  is  usually  soft  and  yielding  and  whose  lower  ribs 
are  not  rigid,  much  may  be  ascertained  by  abdominal 
palpation. 

The  true  pelvis  of  an  infant  is  so  shallow  that  a 
finger  introduced  through  the  rectum  can  be  passed 
right  through  the  pelvis.  Most  of  the  abdomen 
can  be  thus  explored  bimanuallj^  with  tolerable  ease, 
and  an  intussusception  in  most  cases  can  easily  be 
detected. 

In  all  cases  of  intestinal  obstruction  the  intestine 
above  the  seat  of  obstruction  tends  to  become  distended, 
while  that  portion  below  it  remains  empty  and  flaccid. 
The  amount  of  abdominal  distension  then,  taking  into 
consideration  the  duration  of  symptoms,  affords  some 
guide  as  to  the  situation  of  the  obstruction. 

Thus  an  obstruction  high  up  in  the  small  intestine 
will  cause  but  little  if  any  distension ;  an  obstruction 
in  the  large  intestine  quickly  causes  great  distension. 

An  important  but  rare  exception  to  this  is  seen  in 
cases  of  strangulated  diaphragmatic  hernia.  In  these 
cases  there  is  frequently  no  distension  of  the  abdomen ; 
the  abdomen  may  even  be  quite  hollow.  The  reasons 
for  this  are  that  so  much  of  the  intestine  has  passed  up 
through  the  diaphragm  into  the  thorax,  and  that  the 
obstruction  is  often  very  high  up,  involving  the  stomach 
itself.  A  careful  examination  of  the  thorax  helps  in 
the  diagnosis.  Such  cases  are  often,  and  easily,  mis- 
taken for  pneumothorax. 


INTESTINAL    OBSTRUCTION.  I  77 

The  amount  of  urine  passed  by  the  patient  is  some- 
times said  to  afford  help  in  the  diagnosis  of  the  seat 
of  obstruction,  being  small  when  the  obstruction  is 
high  up. 

In  air  cases  of  acute  obstruction,  however,  the  amount 
of  urine  is  diminished,  wherever  the  seat  of  obstruction. 
The  amount  of  urine  passed  depends  on  the  quantity 
of  fluid  absorbed,  and  this  again  depends  not  so  much 
on  the  quantity  of  intestine  available  for  absorption  as 
on  the  amount  of  fluid  ingested  and  the  frequency  of 
the  vomifciog.  A  patient  who  vomits  immediately  after 
drinking  any  fluid,  or  who  is  constantly  vomiting 
independently  of  drinking,  will  naturally  pass  but 
little  urine. 

Finally  it  must  be  admitted  that  in  very  many  cases 
the  exact  diagnosis  of  the  nature  of  an  intestinal 
obstruction  cannot  be  made  with  certainty  until  the 
abdomen  has  been  opened  and  explored.  That  there 
is  a  mechanical  obstruction  which  demands  exploratory 
laparatomy  is  often  the  utmost  that  can  be  said  before 
operation.  And  fortunate  is  the  surgeon  who,  after 
opening  an  abdomen  in  the  belief  that  he  would  find  a 
mechanical  obstruction,  has  never  had  to  confess  that 
he  was  wrong,  and  that  the  symptoms  were  due,  aft^r 
all,  to  some  form  of  inflammatory  condition. 


M 


CHAPTER  XVII. 

HERNIA. 

By  the  term  hernia  is  meant  a  protrusion  of  some  por- 
tion of  the  abdominal  viscera  through  an  opening  in  the 
abdominal  wall.  There  is  therefore  necessarily  direct 
continuity  bet^ween  the  external  swelling  and 
the  viscera  within  the  abdomen. 

The  first  point  to  be  established  therefore  in  the 
examination  of  a  case  of  supposed  hernia  is  whether  this 
continuity  can  be  ascertained  to  exist.  In  most  cases 
this  is  easy  enough.  If  the  tumour  be  lifted  up  or 
drawn  gently  away  from  the  opening  in  the  abdominal 
wall,  and  the  fingers  passed  beneath  it,  the  neck  of  the 
hernia  can  be  felt  extending  as  a  more  or  less  thick 
band  or  cord  passing  into  the  abdomen. 

Swellings  having  their  origin  outside  the  abdomen 
and  unconnected  with  the  latter  have  no  such  neck, 
and  can  be  felt  to  be  separate  from  the  abdomen. 

In  a  case  of  a  scrotal  swelling,  for  example  such 
as  a  hydrocele,  the  fingers  can  be  made  to  meet  above 
the  tumour  between  it  and  the  abdominal  wall,  and 
it  can  be  definitely  ascertained  that  nothing  abnormal 
exists  between  tumour  and  abdomen. 

There  are  some  cases,  however,  in  which  the  existence 
of  this  neck  cannot  be  clearly  ascertained.     A  hernial 


HERNIA.  179 

swelling  may  be  so  large  and  so  closely  apj^lied  to  the 
hernial  opening  as  to  make  it  impossible  to  feel  whether 
a  neck  exists  or  not.  This  is  especially  likely  to  be  the 
case  with  the  more  or  less  globular  umbilical  and 
femoral  hernise,  which  lie  more  directly  over  their  aper- 
tures of  exit  than  do  inguinal  hernige. 

In  the  case  of  the  umbilical  hernia  it  is  very  seldom 
that  any  other  swelling  is  large  enough  to  simulate  hernia 
in  this  way  without  having  decided  characters  of  its 
own  which  render  diagnosis  easy. 

But  with  femoral  hernia  the  case  is  different.  Many 
swellings  in  the  femoral  region  can  easily  simulate 
hernia.  A  mass  of  enlarged  glands,  a  lipoma,  or  other 
tumour,  may  in  this  respect  very  closely  resemble  a 
hernia. 

There  are  two  classes  of  external  swelling  neverthe- 
less which  do  exhibit  continuity  with  the  interior  of  the 
abdomen  and  which  are  not  hernige.  One  is  that  in 
which  a  collection  of  fluid  or  even  a  solid  swelling 
extends  from  the  abdomen  through  its  wall  and  forms 
an  external  swelling.  A  psoas  abscess  extending 
into  the  upper  part  of  the  thigh,  a  collection  of  pus 
tracking  down  through  the  inguinal  canal  into  the 
scrotum  or  through  some  other  spot  in  the  abdo- 
minal wall,  or  peritoneal  fluid  extending  along  an 
unobliterated  funicular  process  of  peritoneum  into 
the  tunica  vaginalis  (congenital  hydrocele),  are  examples 
of  this.  Occasionally  a  mass  of  new  growth  within  the 
abdomen  or  pelvis  may  pass  along  some  weak  spot  in 
the  abdominal  wall,  such  as  the  inguinal  or  femoral 
canal,  and  thus  come  to  simulate  hernia. 

The  other  class  is  that  of  cases  in  which  a  swelling 
originating  outside  the  abdomen  extends  upwards  into 


l8o  SURGICAL    DIAGNOSIS. 

it.  Thus,  a  testis  enlarged  from  inflamraation,  tubercle, 
or  malignant  disease,  may  cause  great  thickening  of  the 
cord,  and  the  latter  may  thus  come  to  resemble,  to  a 
certain  extent,  a  hernial  neck. 

Sometimes  the  spermatic  cord  with  its  covering 
muscle  (cremaster)  may  be  much  thickened  by  hyper- 
trophy, from  having  to  support  a  heavy  swelling  such 
as  a  hydrocele,  that  has  long  been  attached  to  it. 

A  small  swelling,  such  as  an  enlarged  gland  in  the 
femoral  canal  or  a  lipoma  or  encysted  hydrocele  within 
the  inguinal  canal,  may  be  so  deeply  seated  that  it  is 
impossible  to  draw  it  down  sufficiently  to  ascertain 
whether  it  has  a  neck  or  not,  and  difficulties  in  diag- 
nosis may  arise. 

We  may  pass  now  to  the  second  characteristic 
sign  of  a  hernia,  namely  the  impulse  on  coughing. 
The  more  or  less  fluid  contents  of  a  hernia  (gas  or 
liquid)  communicating  freely  with  the  interior  of  the 
abdomen  allow  an  impulse  to  be  transmitted  readily 
from  the  interior  of  the  abdomen  to  the  external  swell- 
ing. Thus  an  impulse  produced  within  the  abdomen  by 
coughing  passes  to  the  hernial  swelling,  where  it  can 
easily  be  felt.  It  is  sometimes  a  little  difficult  to  distin- 
guish the  true  hernial  impulse  from  the  false  impulse 
caused  by  the  movement  of  the  abdominal  wall  in  imme- 
diate contact  with  the  hernia.  But  a  little  care  and 
drawing  the  tumour  as  much  as  possible  away  from  the 
muscle  will  generally  serve  to  obviate  error. 

There  are,  however,  other  swellings  besides  hernige 
which  give  an  impulse  on  coughing.  Any  collection 
of  fluid  which  is  partly  within  and  partly  without 
the  abdomen,  may  give  an  impulse.  A  psoas  abscess 
affords  a  good  example.     So  does  the  column  of  blood 


HERNIA.  l8l 

within  a  large  vein.  Thus  it  happens  sometimes  that  a 
dilated  saphenous  vein  and  a  varicocele  are  mistaken  for 
hernia  on  account  of  the  impulse  which  they  receive  on 
coughing.  The  impulse  received  by  a  dilated  vein  is, 
however,  much  softer  and  less  distinct  than  that  of  a 
hernia,  and  is  best  described  by  the  word  '•'  thrill " 
rather  than  impulse.  No  one  who  has  once  felt  this 
thrill  of  a  varicocele  or  varicose  saphenous  vein  is  likely 
to  confound  it  seriously  with  the  impulse  of  a  hernia. 

Impulse  on  coughing  is  so  commonly  found  in  a 
hernia  and  so  characteristic  of  it  that  it  is  important 
to  bear  well  in  mind  that  there  are  two  kinds  of 
hernia  which  do  not  present  an  impulse.  One  is  the 
hernia  whose  contents  are  solid  {e.g.,  the  omental 
hernia)^  and  the  other  is  the  hernia  which  is  strangu- 
lated. In  neither  of  these  two  cases  can  the  impulse  b 
transmitted  from  the  abdomen  to  the  hernia. 

In  the  case  of  a  hernia  containing  intestine,  reso- 
nance on  percussion  affords  a  valuable  sign.  This 
sign  may,  however,  be  presented  by  rare  cases  of 
abscess  containing  gas,  and  in  cases  of  distension  of  the 
scrotum  with  air  {e.g.,  from  fractured  ribs),  but  neither 
of  these  is  likely  to  be  confounded  in  practice  with 
hernia. 

Reducibility,  if  present,  is,  of  course,  a  very 
valuable  sign  of  hernia,  and  is  especially  valuable  if 
the  reducibility  is  effected  with  the  characteristic  and 
well-known  gurgle,  showing  that  the  contents  consist 
of  both  gas  and  liquid.  Gurgling  often  affords  evi- 
dence of  hernia,  even  when  the  swelling  is  not  reducible. 
Fluid  swellings,  such  as  psoas  abscess  and  varicocele, 
are  also  reducible,  but  in  these  cases  the  swelling  sub- 
sides impalpably  and  without  this  gurgle.     If  there  be 


1 82  SURGICAL   DIAGNOSIS. 

any  doubt  between  hernia  and  a  venous  swelling,  such 
as  varicocele  or  a  varicose  saphenous  vein,  the  doubt 
can  be  cleared  up  by  reducing  the  swelling,  then 
putting  a  finger  over  the  inguinal  or  femoral  ring,  and 
then  getting  the  patient  to  stand  up.  The  venous 
swelling  which  fills  from  below  soon  returns  in  spite  of 
the  pressure  of  the  finger.  But  a  hernia  is  thereby 
prevented  from  descending. 

Some  help  in  the  diagnosis  of  hernia  can  sometimes 
be  obtained  from  careful  palpation  of  the  abdomen,  and 
especially  of  the  iliac  fossa.  If  the  abdominal  wall  be 
sufficiently  lax,  a  resisting  mass  may  be  felt  on  the 
inner  aspect  of  the  hernial  ring.  This  is  the  band  of 
mesentery  or  omentum  passing  towards  the  hernial 
aperture.  In  the  case  of  femoral,  and  still  more  of 
obturator,  hernia  a  careful  bimanual  examination  with 
one  finger  in  the  vagiua  or  rectum  may  be  of  the 
utmost  value,  revealing  the  presence  of  this  intra- 
abdominal band. 

History. — Most  hernige  begin  as  small  protrusions 
at  the  site  of  the  hernial  aperture  in  the  abdominal 
wall,  and  then  gradually  and  slowly  enlarge.  They 
tend  usually  to  pass  away  from  the  situation  of  the 
neck,  as  when,  for  example,  an  inguinal  hernia  descends 
into  the  scrotum,  or  a  femoral  hernia  passes  upwards 
and  outwards  across  the  groin. 

Sometimes  a  hernia  begins  by  suddenly  appearing 
as  a  large  swelling.  These  are  usually  cases  in  which 
the  hernial  contents  have  descended  into  an  already 
existing  sac,  such  as  an  unobliterated  funicular  process 
of  peritoneum  (congenital  hernia). 

A  history  of  the  gradual  descent  towards  the  scrotum 
will  often   help  in  the  diagnosis  between  hernia  and 


HERNIA.  183 

sucli  swellings  as  hydrocele,  which  begin  below  and  in 
their  growth  extend  upwards. 

Diagnosis  of  the  different  anatomical 
Varieties  of  Hernia. 

The  diagnosis  between  inguinal  and  femoral  hernia 
sometimes  presents  a  difficulty. 

The  diagnosis  is  made  partly  by  the  early  history, 
which  may  indicate  the  exact  spot  at  which  the  hernia 
first  made  its  appearance  ;  partly  by  the  shape  of  the 
swelling.  A  femoral  hernia  is  usually  rounded  or 
semi-globose,  or,  if  oval,  has  its  long  axis  parallel  to 
Poupart's  ligament;  an  inguinal  hernia  is  usually 
pyriform,  or,  if  oval,  has  its  long  axis  more  or  less 
in  the  line  of  the  spermatic  cord  or  round  ligament. 
If  the  hernia  is  small  the  situation  of  it  above  or  below 
the  inner  end  of  Poupart's  ligament  may  suffice  to  show 
whether  we  are  dealing  with  an  inguinal  or  a  femoral 
hernia.  Larger  hernise  come  to  overlap  the  ligament. 
If  the  hernia  be  lifted  up  or  drawn  down  it  will,  how- 
ever, generally  be  easy  to  feel  the  ligament  and  the 
pubic  spine  below  and  outside,  or  above  and  inside  the 
inguinal  and  femoral  hernia  respectively. 

The  somewhat  rare  interstitial  inguinal  hernia,  which 
are  usually  rounded,  are  easily  distinguished  from 
femoral  hernias  by  being  situated  wholly  above  Poupart's 
ligament. 

An  obturator  hernia  resembles  a  femoral  hernia  in 
situation,  but  the  swelling  is  much  more  deeply  seated, 
and  therefore  much  less  distinct.  Pain  along  the  inner 
side  of  the  thigh  in  the  course  of  the  obturator  nerve 
may  also  afford  help  in  the  diagnosis. 


184  STTROTCAL   DIAGNOSIS. 

The  variety  of  inguinal  hernia,  known  as  congenital 
hernia,  has  to  be  distinguished  from  acquired  hernia. 

In  the  former  the  sac  is  formed  by  some  portion  of 
the  processus  vaginalis  of  the  peritoneum,  which,  as  the 
result  of  congenital  malformation,  has  not  undergone 
its  normal  closure  during  foetal  or  early  infantile  life. 

In  its  most  marked  form,  in  which  the  hernia  descends 
into  the  tunica  vaginalis  itself,  the  diagnosis  is  easily 
made  by  observing  that  the  testis  is  almost  completely 
surrounded  by  or  buried  in  the  hernia.  In  an  acquired 
hernia  the  testis  can  usually  be  felt  without  difficulty  at 
the  lower  and  back  part  of  the  hernia. 

The  funicular  variety,  in  which  the  hernia  descends 
into  the  funicular  portion  only  of  this  peritoneal  process, 
the  tunica  vaginalis  itself  being  shut  off,  can  often  be 
diagnosed  by  its  shape.  It  is  narrow  in  proportion  to 
its  length,  being  confined  in  the  tubular  funicular 
process.  A  hernia  which,  on  its  first  appearance, 
descends  suddenly  into  the  scrotum,  is  probabl}^  a 
congenital  hernia. 

Most  congenital  hernise  begin  in  early  life,  but  it 
must  be  remembered  that  they  may  make  their  first 
appearance  at  any  age.  It  is  the  abnormal  condition 
of  the  sac,  and  not  the  hernia,  which  is  present  at 
birth,  i.e.,  congenital  in  the  strict  sense  of  the  word. 

Diagnosis  of  the  Nature  of  the  Hernial 
Contents. 

Most  hernia3  contain  intestine  or  omentum  or  both. 
Some  also  contain  more  or  less  peritoneal  fluid. 
Rarely  do  hernise  contain  other  abdominal  viscera,  such 
as  the  ovary,  bladder,  appendix  vermiformis,  &c. 


HERNIA.  185 

Herniae  that  contain  intestine  generally  have  gas  in 
them,  and  are  consequently  resonant  on  percussion. 
Gurgling,  indicating  the  presence  of  gas  and  liquid, 
also  denotes  that  intestine  is  present. 

Omentum  in  a  hernia  can  often  be  recognised  by 
its  firmness  and  nodularity.  Especially  is  this  likely  to 
be  the  case  when  the  omentum  has  lain  long  in  the  sac 
and  has  become  thickened,  fibrous,  hard  and  lumpy. 
Umbilical  herniee  almost  always  contain  some  omentum, 
because  of  the  close  proximity  of  the  latter  to  the 
umbilical  ring. 

Fluid  in  a  hernial  sac  is  commonly  met  with  in  cases 
of  strangulation,  but  is  sometimes  found  apart  from 
this  condition. 

An  old  hernial  sac  may  become  filled  with  fluid  if 
the  neck  of  the  sac  has  become  closed,  e.g.^  by  a  plug 
of  omentum.  Such  a  spurious  "  hydrocele  of  a  hernial 
sac,"  as  it  is  called,  may  resemble  very  closely  an 
ordinary  irreducible  hernia  as  regards  its  anatomical 
position  and  shape. 

But  the  presence  of  fluid  within  it  is  usually  easily 
recognised  by  ordinary  physical  signs  ;  and  unless  the 
wall  of  the  sac  be  extremely  thick,  or  the  quantity  of 
fluid  very  small,  translucency  is  easily  detected. 

Hernia  of  the  appendix  can  scarcely  be  diagnosed 
nntil  the  sac  has  been  opened  by  operation. 

Hernia  of  the  ovary  may  be  diagnosed  in  children 
without  much  diflftculty ;  a  small  oval  lump  with  a 
narrow  cord  extending  upwards  from  it  is  likely  to  be 
an  ovary.  In  adults  a  hernia  of  the  omentum  is  likely 
to  simulate  hernia  of  the  ovary.  A  clear  history  of 
increased  pain  during  menstruation  may  help  in  the 
diagnosis  of  hernia  of  the  ovary. 


1 86  SURGICAL    DIAGNOSIS. 

Hernia  of  the  bladder  may  sometimes  be  suspected 
from  the  hardness  of  the  swelling  due  to  the  greater 
thickness  of  the  muscular  wall  of  the  bladder.  If  the 
diagnosis  be  suspected,  examination  with  a  metallic 
sound  or  catheter  may  show  that  the  bladder  is  drawn 
towards  the  hernial  opening. 

Diagnosis  of  the  Condition  of  the  Hernial 

Contents. 

A  hernia  may  be  in  any  one  of  the  following 
conditions  :  Reducibility — Simple  irreducibility — In- 
flammation— Obstruction — Strangulation.  The  diag- 
nosis of  the  first  two  presents  no  difiiculty,  and  need 
not  be  discussed. 

The  diagnosis  of  the  third  depends  on  the  local 
signs  of  inflammation — tenderness,  heat,  redness, 
oedema,  &c.  Signs  of  local  inflammation  are  of  course 
common  with  strangulation,  and  they  must  not  be 
taken  as  indicating  mere  inflammation  unless  the  more 
serious  and  important  signs  of  strangulation  are  absent. 

Obstruction  is  diagnosed  by  constipation,  together 
usually  with  some  increase  in  the  size  of  the  hernia 
and  irreducibility.  Both  inflamed  and  obstructed 
hernise  are  apt  to  pass  at  very  short  notice  into  a 
condition  of  strangulation. 

Strangulation  of  a  hernia  containing  intestine  is 
characterised  chiefly  by  two  general  symptoms,  vomit- 
ing and  constipation,  of  which  the  former  is  by  far  the 
more  important,  and  three  local  signs — irreducibility, 
absence  of  impulse,  and  tension. 

The  general  symptoms  are  those  of  intestinal 
obstruction,  already  discussed  (p.  167). 


HERNIA.  187 

The  absence  of  impulse  is  due  to  the  free  communi- 
cation between  the  contents  of  the  hernia  and  those  of 
the  abdomen  having  been  cut  oK  The  tension  is  due 
to  the  swelling  of  the  contents  from  congestion  and  to 
exudation  of  fluid  into  the  sac. 

In  the  later  stages  of  strangulation  the  symptoms 
of  peritonitis  and  septic  absorption  may  be  added  to 
those  above  mentioned. 

Local  pain  and  tenderness  are  generally  present 
with  strangulation.  They  are  due  rather  to  the  accom- 
panying inflammation  than  to  the  strangulation  itself. 
They  may  be  completely  absent,  especially  in  old 
people. 

Strangulation  of  omentum  may  present  symptoms 
similar  to  those  of  strangulation  of  the  intestine,  but 
they  are  usually  very  much  less  marked.  Vomiting 
may  be  entirely  absent. 

Gangrene  and  ulceration  are  late  complications,  and 
may  be  diagnosed,  or  at  least  suspected,  partly  by  the 
duration  and  severity  of  the  symptoms  of  strangula- 
tion, partly  by  the  general  symptoms  of  septic  poisoning, 
and  partly  by  the  local  signs.  Of  the  latter,  absence 
of  tension,  crackling,  and  redness  of  the  skin  are 
perhaps  of  the  most  importance.  It  is  important,  how- 
ever, to  remember  that  any  or  all  of  these  symptoms 
and  signs  may  be  absent,  even  when  gangrene  has 
undoubtedly  occurred. 


CHAPTER  XVIII. 
DIAGNOSIS  OF  GALL-STONES. 

The  surgery  of  the  biliary  passages  has,  in  the  last  few 
years,  made  very  rapid  strides.  The  diagnosis  of  gall- 
stones has,  therefore,  become  a  matter  of  great  import- 
ance, not  only  to  the  physician  and  to  the  general 
practitioner,  by  whom  such  cases  are  usually  first  seen, 
but  to  the  operating  surgeon  as  well. 

Gall-stones  may  lie  quietly  in  the  gall-bladder  or 
even  in  the  bile-ducts  for  months  or  years  and  cause 
no  symptoms  at  all.  Under  these  conditions,  diagnosis 
of  their  presence  is  impossible,  except  in  the  very  rare 
cases  in  which  they  can  actually  be  felt  grating  against 
one  another  in  the  gall-bladder,  or  in  those  cases  in 
which  from  time  to  time  a  gall-stone  quietly  makes  its 
way  into  the  intestine,  and  is  subsequently  discovered 
in  the  motions. 

But  even  in  these  cases  it  is  rare  to  find  that  there 
have  been  no  symptoms  at  all. 

The  symptoms  of  gall-stones  in  the  vast  majority  of 
cases  are  those  of  one  or  other  of  two  conditions. 

1.  Obstruction  of  some  portion  of  the  biliary 
passages. 

2.  Inflammation  of  some  portion  of  the  biliary 
passages  and  of  the  surrounding  structures. 


DIAGNOSIS    OF   GALL-STONES.  189 

In  most  cases  these  two  conditions  are  associated, 
but  it  is  well  to  consider  them  separately,  since  the 
symptoms  to  which  each  gives  rise  are  very  different. 

It  is  well  also  to  remember  that  in  most  cases  the 
diagnosis  of  gall-stones  is  the  diagnosis  of  one  or  other 
or  both  of  these  conditions.  There  are  other  rarer 
conditions  which  cause  obstruction  or  inflammation  of 
the  biliary  passages,  and  these,  when  they  do  occur, 
are  extremely  apt  to  be  mistaken  for  the  effects  of  gall- 
stones. 

I.  Obstruction  of  the  biliary  passages. 

An  obstruction  to  any  part  of  the  biliary  passages 
follows  the  usual  pathological  law  with  regard  to 
obstruction  of  any  hollow  viscus  or  tube.  The  part 
behind  the  obstruction  becomes  distended  with  secre- 
tion, then  undergoes  dilatation  and  hypertrophy. 

A  gall-stone  impacted  in  the  cystic  duct  causes 
distension  of  the  gall-bladder.  The  gall-bladder 
gradually  enlarges,  and  at  the  same  time  usually 
becomes  thickened ;  its  walls  become  hypertrophied 
in  the  more  or  less  vain  attempt  to  overcome  the 
obstruction. 

If  this  distension  of  the  gall-bladder  be  unaccom- 
panied by  any  inflammation,  it  will  usually  be  painless 
or  nearly  so.  A  sense  of  discomfort  or  a  dragging  pain 
in  the  right  hypochondrium  due  to  the  weight  of  the 
enlarged  and  distended  gall-bladder  may  be  the  only 
symptom  of  which  the  patient  is  aware.  Chronic  and 
considerable  distension  of  the  gall-bladder  is  in  these 
cases  the  only  tangible  evidence  of  gall-stones,  and  in 
the  absence  of  any  evidence  pointing  to  any  other 
kind    of    obstruction,   is    to   be     considered     as    pre- 


IQO  SURGICAL   DIAGNOSIS. 

sumptive  evidence  of  the  existence  of  one  or  more  gall- 
stones. 

A  gall-stone  impacted  in  the  common  bile-duct, 
that  is  below  the  point  of  junction  of  the  cystic  and 
hepatic  ducts,  causes  dilatation,  not  only  of  the  cystic 
duct  and  gall-bladder,  but  also  of  all  the  hepatic  ducts. 
The  whole  of  the  hepatic  secretion  is  therefore  pent  up 
behind  the  obstruction.  The  hepatic  duct  and  all  its 
branches  within  the  liver  become  distended.  The 
elastic  and  distensile  liver  itself  becomes  dilated.  Two 
important  signs,  therefore,  appear  which  are  not  present 
with  obstruction  of  the  cystic  duct  alone.  These  are 
enlargement  of  the  liver  and  jaundice. 

Obstruction  of  the  cystic  duct  in  itself,  as  has  already 
been  mentioned,  affords  presumptive  evidence  of  the 
presence  of  gall-stones,  since  these  are  by  far  the  most 
common  cause  of  an  obstruction  in  this  situation. 

Obstruction  of  the  common  duct,  on  the  other  hand, 
does  not  in  itself  ajBford  presumptive  evidence  of  gall- 
stones. Gall-stones  are  not  the  commonest  cause  of 
obstruction  of  the  common  duct.  Cancer  of  the  head 
of  the  pancreas  or  the  common  bile-duct  itself,  catarrh 
of  the  biliary  passages,  and  chronic  pancreatitis,  are  the 
common  causes  of  obstruction  in  this  situation. 

Gall-stones  in  this  situation  are  to  be  diagnosed  only 
after  these  other  causes  have  been  carefully  considered 
and  excluded,  and  only  if  other  evidence  of  gall-stones 
can  be  obtained  from  the  history  of  the  case.  A 
steadily  progressive  painless  jaundice,  together  with 
enlargement  of  the  liver,  if  due  to  obstruction  of  the 
common  duct  (for  it  may  depend  upon  disease  of  the 
liver  itself),  is  generally  caused  by  carcinoma. 

And  carcinoma,  at  least  in  its  early  stages,  does  not 


DIAGNOSIS    OF   GALL-STONES.  191 

usually  cause  any  other  signs  than  those  above- 
mentioned.  The  patient  with  carcinoma  is  almost  in- 
variably of  middle  age  or  beyond  ;  but  so,  as  a  rule,  is 
the  patient  with  gall-stones,  so  that,  unless  the  patient 
is  young,  we  do  not  get  much  help  from  consideration 
of  the  age. 

The  early  history  of  the  case  may,  however,  afford 
great  help,  and  point  strongly  to  gall-stones.  Thus  gall- 
stones may  have,  on  previous  occasions,  been  passed 
per  anum.  The  previous  existence  of  gall-stones 
affords,  however,  no  proof  of  the  absence  of  carcinoma, 
since  gall-stones  and  carcinoma  frequently  co-exist. 

A  history  of  similar  attacks  which  have  passed  off, 
and  especially  a  history  of  similar  attacks  having  passed 
off  quite  suddenly,  points  towards  gall-stones  and  away 
from  carcinoma.  Attacks  of  biliary  colic  point  to  gall- 
stones. So  does  a  long  history  extending  over  several 
years. 

Marked  emaciation  is  common  with,  and  points 
strongly  towards,  carcinoma ;  but  it  must  not  be 
forgotten  that  very  considerable  emaciation  may  occur 
with,  and  be  due  to,  the  jaundice  itself,  quite  apart 
from  its  causation. 

Elevation  of  temperature,  marked  tenderness,  and 
other  signs  of  inflammation,  point  towards  gall-stones 
rather  than  to  carcinoma. 

2.  Inflammation  of  the  biliary  passages. 

Gall-stones  lying  in  any  part  of  the  biliary  passages 
do  not  in  themselves  cause  pain  by  any  mere  mechanical 
irritation  of  the  parts.  The  gall-bladder  and  -ducts,  like 
other  abdominal  viscera,  are  not  sensitive  to  mechanical 
irritation.  Pain  due  to  gall-stones  is  caused  either  by 
distension  of  the  parts  behind  the  obstructing  stone,  or 


192  SURGICAL    DIAGNOSIS. 

to  inflammation  of  the  biliary  passages  and  of  surround- 
ing parts. 

But  gall-stones  may,  by  their  irritation,  cause  ulcera- 
tion of  the  gall-bladder  or  its  ducts,  and  this  in  its 
turn  may  lead  to  various  inflammatory  conditions  of 
surrounding  parts. 

An  ulcerated  gall-bladder  may  perforate  and  set  up  a 
peritonitis,  local  or  general,  according  to  the  intensity 
of  the  inflammation  and  the  amount  of  extravasated 
material. 

Perforation  is  recognised  by  the  ordinary  symptoms 
common  to  perforative  peritonitis  anywhere.  The 
situation  of  the  pain  in  its  early  stages  in  the  region  of 
the  gall-bladder,  and  perhaps  a  previous  history  point- 
ing to  gall-stones,  will  indicate  the  nature  of  the  per- 
foration. 

More  common,  however,  than  the  sudden  perforation 
is  the  gradual  perforation  of  an  ulcer,  which  leads  to 
the  formation  of  adhesions  limiting  or  preventing  extra- 
vasation with  the  general  peritoneal  cavity.  Suppura- 
tion may  thus  be  set  up  in  the  neighbourhood  of  the 
biliary  passages.  This  may  extend  to  the  portal  vein, 
or  to  the  cellular  tissue  behind  the  peritoneum,  or  to  the 
liver  itself.  When  occurring  in  any  of  these  situations 
it  is  extremely  likely  to  lead  to  septic  absorption,  accom- 
panied by  the  usual  symptoms,  high  temperature  and 
rigors,  together  with  local  tenderness  and  pain,  and 
often  more  or  less  jaundice.  The  condition  is  a  most 
serious  and  dangerous  one. 

Suppuration  is  not  infrequently  set  up  within  the 
gall-bladder,  and  is  generally  associated  with  gall- 
stones. The  diagnosis  is  a  matter  of  much  importance, 
owing  to  the  danger  of  perforation,  and  the  consequent 


DIAGNOSIS    OF   GALL-STONES.  1 93 

necessity  of  a  prompt  operation  for  the  evacuation  of 
the  pus. 

Acute  local  pain  and  tenderness,  together  with  the 
symptoms  of  more  or  less  absorption,  point  to  suppura- 
tion in  the  gall-bladder,  and  if  the  latter  can  be  felt  to 
be  distended  the  diagnosis  is  tolerably  clear. 

Suppuration  may,  however,  occur  much  more  quietly 
within  the  gall-bladder,  and  no  very  definite  signs  of  its 
presence  ma}^  have  been  detected,  until  a  sudden  perfo- 
ration, or  the  death  of  the  patient,  reveal  the  true  state 
of  affairs. 

A  catarrhal  inflammation  of  the  gall-bladder  is 
an  extremely  common  complication  of  gall-stones.  It 
cannot  be  too  strongly  insisted  upon  that  it  is  catarrhal 
inflammation  of  the  gall-bladder  that,  in  the  great 
majority  of  cases  of  biliary  colic,  is  the  immediate  cause 
of  the  pain. 

A  distended  gall-bladder,  due  to  a  stone  impacted  in 
the  duct,  does  not  cause  severe  pain,  because,  under 
ordinary  conditions,  the  tension  within  the  gall-bladder 
is  not  great.  But  let  the  tension  in  such  a  case  be 
increased  by  a  catarrhal  inflammation  of  the  mucous 
membrane,  and  the  comparatively  slight  amount  of  extra 
secretion  into  the  gall-bladder  is  then  sufficient  to  cause 
most  severe  pain.  This  pain  may  last  hours  or  days 
until  the  inflammation  has  subsided,  or  some  of  the  fluid 
contents  have  escaped  along  the  duct. 

The  catarrhal  inflammation  of  the  distended  and  more 
or  less  diseased  gall-bladder,  and  the  associated  spasm 
caused  thereby,  is  the  cause  of  the  violent  attacks  of 
pain  that  are  so  often  associated  with  gall-stones  in  the 
cystic  duct. 

Gall-stone  colic  is  not  due  to  the  scraping  of  a  stone 

N 


194  SURGICAL   DIAGNOSIS. 

along  the  duct.  In  most  cases  the  stone  is  much  too 
large  to  pass  through  the  duct.  Examination  of 
museum  specimens  shows  plainly  the  impossibility  of 
gall-stones  moving  along  the  duct  unless  they  are  of 
small  dimensions.  Large  gall-stones  that  pass  into  the 
small  intestine  do  so  by  ulcerating  directly  through  the 
wall  of  the  gall-bladder  or  -duct. 

A  gall-stone  impacted  in  the  intestine  may  be  diag- 
nosed with  considerable  certainty  by  the  sudden  onset, 
in  an  elderly  person,  of  symptoms  of  acute  intestinal 
obstruction  without  abdominal  distension.  If  the  patient 
be  fat,  or  if  she  give  a  history  of  previous  symptoms 
pointing  to  gall-bladder  trouble,  the  diagnosis  is 
confirmed.  Mr.  Harold  Barnard  has  pointed  out  that 
the  period  of  vomiting  may  be  divided  into  three  stages  : 
a  first  stage  of  violent  vomiting  when  the  stone  first 
enters  the  duodenum  ;  a  second  stage  of  remission  when 
the  stone  passes  down  the  intestine  and  away  from 
the  neighbourhood  of  the  stomach ;  a  third  stage  of 
renewed  vomiting  caused  by  the  impaction  of  the  stone, 
generally  low  down  in  the  small  intestine.  The  same 
observer  points  out  that  in  the  first  stage  the  pain  is 
referred  to  the  epigastrium,  while  in  the  second  and 
third  stages  it  is  felt  at  the  umbilicus.  This  shifting  of 
the  pain  may  be  of  much  help  in  the  diagnosis. 


CHAPTER   XIX. 

DISEASES  OF  THE  RECTUM  AND  ANUS. 

In  the  investigation  of  a  case  of  disease  of  these  parts 
the  surgeon  should,  after  asking  the  usual  questions 
common  to  all  surgical  cases  (see  chap,  ii.),  direct  his 
attention  especially  to  the  following  four  points  : 

1.  The  presence  or  absence  of  pain,  its  nature,  degree, 

situation,  duration,  and  whether  it  is  aggravated 
by  the  act  of  defgecation. 

2.  The  mode  in  which  the  rectum  performs  its  normal 

functions  —  whether  there  is  constipation  or 
diarrhoea,  whether  there  is  a  constant  or  fre- 
quent desire  to  empty  the  rectum. 

3.  Whether  there  is  any  abnormal  discharge  from 

the  rectum,  and  especially  of  blood,  mucus,  or 
pus. 

4.  Whether  during  defaecation,  or  at  any  other  time, 

there  is  any  protrusion  of  the  wall  of  the  bowel 
or  other  structure. 
It  is  well  also  to  inquire  into  the  functions  of  the 
neighbouring  pelvic  organs,  bladder  and  uterus,  and  to 
direct  attention  to  the  state  of  the  general  health,  and 
of  the  principal  viscera  of  the  body,  notably  the  liver 
and  heart. 

Much  can  be  learnt  about  the  nature  of  the  case  from 


196  SURGICAL   DIAGNOSIS. 

judicious  questioning  with  regard  to  the  symptoms  that 
are  present. 

Each  of  the  above  four  groups  of  symptoms  may  be 
discussed  separately. 

I.  Pain. — As  a  general  rule  it  may  be  stated  that 
diseases  involving  the  anus  and  lower  part  of  the  rectum, 
which  are  supplied  with  nerves  of  common  sensation, 
are  more  likely  to  cause  pain  than  those  which  involve 
the  middle  and  upper  parts  which  are  not  so  supplied. 
It  is  especially  cracks,  ulcers,  and  other  breaches  of 
surface  involving  the  mucous  membrane  at  the  anus 
itself  that  give  rise  to  the  most  severe  pain.  A  history 
of  severe  pain  started  by  the  act  of  deftecation,  and  per- 
sisting for  a  considerable  time  afterwards,  is  in  itself 
almost  sufficient  for  the  diagnosis  of  an  anal  fissure  or 
ulcer.  It  must  be  remembered,  however,  that  the  anal 
fissure  which  gives  rise  to  this  symptom  is  not  neces- 
sarily the  sole  disease  from  which  the  patient  is  suffering. 
It  is  quite  common  for  a  fissure  to  exist  by  the  side  of 
a  pile.  In  fact,  any  crack  about  the  mucous  membrane 
of  an  inflamed  part  at  the  anus  may  give  rise  to  this 
symptom. 

Acute  inflammatory  affections  outside  the  rectum, 
such  as  ischiorectal  abscess,  may  give  rise  to  a  good  deal 
of  pain,  which  is  generall}^  more  constant  and  less 
severe  than  the  pain  of  an  ulcer  or  fissure  of  the  amis. 
Mere  ulceration  of  the  rectum  above  the  anus,  whether 
simple  or  malignant,  is  not  painful  unless  it  happens  to 
be  acutely  inflamed,  or  is  accompanied  by  inflammation 
which  has  spread  to  the  surrounding  tissues  outside  the 
rectum.  Much  pain  in  connection  with  a  carcinomatous 
stricture  of  the  rectum,  for  example,  generally  indicates 
the  presence  of  inflammation  of  the  cellular  tissue  out- 


DISEASES    OF    THE    RECTUM    AND    ANUS.       197 

side  the  rectum.  Sometimes  it  indicates  extension 
of  growth  to  neighbouring  large  nerves,  such  as  the 
sciatic. 

Suppuration  around  the  rectum  is  not  usually  painful 
provided  that  there  is  a  free  exit  for  the  pus.  An 
ordinary  fistula  is  not  particularly  painful  unless  there 
is  retention  of  pus. 

A  very  sharp  pricking  pain,  much  aggravated  by 
defgecation,  sometimes  indicates  the  presence  of  a 
foreign  body  such  as  a  fishbone,  splinter  of  wood,  or 
some  similar  substance. 

2.  Rectal  functions.  —  Both  constipation  and 
diarrhoea  may  be  due  to  some  general  disease,  or  to  some 
local  affection  of  the  intestine  altogether  above  the 
rectum. 

Constipation  due  to  disease  of  the  rectum  may  be 
caused  by  some  actual  obstruction  to  the  lumen  of  the 
bowel,  such  as  stricture,  or  the  pressure  of  a  tumour 
from  the  outside  ;  or  it  may  be  due  merely  to  atony  of 
the  wall  of  the  rectum  from  habitual  over-distension 
with  fa3ces ;  or  it  may  be  due  to  the  fact  that  defsecation 
is  painful,  and  that  the  patient  consequently  defers  the 
act  as  long  as  possible.  The  constipation  frequently 
seen  in  connection  with  fissure  of  the  anus  is  a  common 
example  of  the  latter. 

Diarrhoea,  if  due  to  local  disease  of  the  rectum, 
generally  indicates  some  ulceration  of  the  wall  of  the 
bowel.  A  mere  inflammation  of  the  mucous  membrane 
may  produce  the  same  effect.  It  is  not  uncommon  to 
find  diarrhoea  associated  with  stricture. 

A  frequent  desire  to  empty  the  rectum  is  often 
present  when  there  is  ulceration,  or  tumour,  or  other 
source  of  irritation  in  it.     Indeed,  a  feeling  that  there 


19^  SUHGICAL   DIAGN0>SIS. 

is  something  there,  a  consciousness  of  the  presence  of  a 
rectum,  is  a  common  accompaniment  of  most  diseases 
of  this  organ,  and  especially  of  inflammatory  affections. 

The  shape  of  the  motions  is  a  matter  of  very  little 
importance.  It  is  often  said  that  narrow  tape-like  or 
pipe-like  motions  are  a  valuable  indication  of  stricture. 
It  is  true  that  a  stricture  at  or  close  to  the  anus  will 
produce  motions  of  this  character,  but  a  stricture  in 
this  situation  can  be  diagnosed  with  far  more  certainty 
by  direct  examination.  But  motions  of  the  same 
character  may  be  passed  when  there  is  no  stricture  at 
all,  but  only  a  spasmodic  condition  of  the  sphincter. 
In  the  case  of  a  stricture  high  up  in  the  rectum,  out  of 
reach  of  the  finger,  the  motions  are  by  no  means  neces- 
sarily altered  in  shape. 

Conclusions  drawn  from  the  shape  and  size  of  the 
motions  are  practically  valueless. 

3.  Abnormal  discharges. — The  passage  of  blood 
is  one  of  the  commonest  signs  of  rectal  disease. 

The  blood  may  come  from  some  part  of  the  intestinal 
tract  above  the  rectum,  e.g.,  from  the  colon,  small 
intestine,  or  stomach.  In  this  case  the  character  of  the 
blood  is  generally  more  or  less  altered  by  the  intestinal 
juices.  The  higher  the  source  of  haemorrhage  the 
darker  and  more  tarry  in  appearance  is  the  blood.  The 
existence  of  other  signs  and  symptoms  of  disease  else- 
where will  generally  suffice  in  these  cases  to  show  that 
the  blood  is  not  derived  from  the  rectum  itself. 

Painless  haemorrhage  from  the  rectum  in  the  case 
of  a  child  usually  indicates  a  simple  polypus.  If  the 
polypus  is  well  above  the  region  of  the  anus,  and  is  not 
prolapsed,  there  are  often  no  other  symptoms  at  all. 
Hence   the   importance  of    making    a   thorough    local 


DISEASES    OF   THE   RECTUM   AND   ANUS.       1 99 

examination  in  the  case  of  a  child  presenting  this 
symptom. 

Painless  haemorrhage  without  other  symptoms  in  an 
adult  generally  indicates  internal  haemorrhoids.  Any 
kind  of  tumour  or  ulceration  may  also  cause  painless 
haemorrhage  if  it  is  situated  above  the  sphincter,  but 
the  presence  of  extensive  ulceration  usually  causes  the 
passage  of  slimy  mucus  as  well  as  blood. 

Mucus. — Inflammation  and  congestion  of  the  rectal 
mucous  membrane  or  of  any  tumour  springing  from  it 
is  apt  to  cause  a  discharge  of  mucus.  A  heemorrhoid, 
for  example,  gripped  by  the  sphincter  ani,  exudes  a 
considerable  quantity  of  mucus. 

Pus  in  quantity  indicates  either  extensive  ulceration 
of  the  rectum  or  more  often  the  existence  of  a  smus 
transmitting  the  contents  of  an  abscess  situated  outside 
the  rectum.  Abscesses  connected  with  disease  of 
some  neighbouring  bone  or  joint,  or  of  one  of  the 
pelvic  or  abdominal  viscera,  or  of  the  cellular  tissue 
near  the  rectum,  may  discharge  their  contents  into  the 
rectum. 

4.  Protrusion  at  the  anus  in  a  child  generally 
means  prolapse ;  if  the  protrusion  be  small  and 
rounded  it  is  likely  to  be  a  polypus. 

An  intussusception  at  a  late  stage  may  also  protrude, 
but  is  easily  recognised  by  the  severity  of  the  accom- 
panying symptoms  and  by  the  passage  of  a  probe 
between  it  and  the  anus.  A  prolapse,  being  an 
inversion  of  the  lower  part  of  the  rectum,  does  not 
permit  of  a  probe  being  passed  up  by  the  side  of  it : 
the  skin  and  mucous  membrane  are  seen  to  be  directly 
continuous  with  each  other. 

Pedunculated  innocent  tumours  occasionally  appear 


2  00  SURGICAL   DIAGNOSIS. 

outside  tlie  anus  in  the  case  of  adults  as  well  as  in 
children. 

Protrusion  at  the  anus  in  an  adult  generally 
indicates  hgemorrhoids,  usually  easily  recognised  by 
their  colour  and  by  their  attachment  to  the  neigh- 
bourhood of  the  anus.  The  protrusion  of  a  complete 
ring  of  mucous  membrane  (including  perhaps  muscular 
and  serous  layers  as  well)  indicates  prolapse.  Haemor- 
rhoids never  form  a  protrusion  of  more  than  half  an 
inch  to  one  inch.  A  prolapse  may  measure  several 
inches  in  length. 

In  elderly  subjects  hgemorrhoids  and  a  certain  amount 
of  prolapse  often  co-exist. 

Malignant  tumours  rarely  become  prolapsed,  but  if 
small  may  be  found  at  the  apex  of  a  prolapsed  portion 
of  bowel. 

Pedunculated  tumours  such  as  simple  polypus  often 
present  at  the  anus,  and  if  small  may  present  some 
resemblance  to  a  pile.  The  brighter  colour  and  the 
absence  of  any  attachment  to  the  anus  are  usuall}^ 
sufficient  for  the  diagnosis. 

Physical  examination. — The  importance  of 
making  a  thorough  visual  and  digital  examination  in 
every  case  of  disease  of  the  rectum  or  anus  cannot  be 
insisted  upon  too  strongly.  No  diagnosis  should  be 
made,  still  less  should  any  treatment  be  undertaken, 
until  such  an  examination  has  been  made.  The 
practitioner  should  be  on  his  guard  against  accepting 
too  readily  an}^  diagnosis,  such  as  "  piles,"  that  the 
patient  himself  may  have  made,  or  that  has  been  made 
by  any  one  else.  Only  too  often  does  a  case  of  so- 
called  "  piles  "  turn  out,  on  examination,  to  be  one  of 
condylomata,  fissure,   polypus,    or    even    cancer.     Nor 


DISEASES    OF    THE    RECTUM    AND    ANUS.       201 

should  it  be  forgotten  that  a  comparatively  simple 
affection,  such  as  piles  or  fistula,  may  not  be  the  only 
disease  that  is  present,  nor  even  the  principal  one. 
The  piles,  fistula,  or  fissure  may  be  only  an  accompani- 
ment of  some  much  more  serious  affection,  such  as 
stricture  or  cancer.  Only  too  often  does  one  see  cases 
in  which  piles  have  been  diagnosed,  and  even  treated, 
while  a  co-existing  carcinoma  has  been  completely 
overlooked  owing  to  careless  or  insufficient  examination. 

The  local  examination  should  be  preceded  by  a  care- 
ful examination  of  the  abdomen,  tp  detect  the  presence 
of  any  tumour,  enlarged  liver,  or  other  cause  or  accom- 
paniment of  the  rectal  disease.  An  examination  of  the 
neighbouring  genital  and  urinary  organs  (vagina, 
urethra,  bladder)  may  also  be  necessary  before  a 
complete  diagnosis  can  be  made. 

For  a  proper  examination  of  the  anal  region,  a  good 
light  is  essential,  and  the  patient  should  lie  on  his  side 
with  the  knees  drawn  up  and  with  the  buttocks  facing 
the  light. 

Superficial  inflammatory  or  other  affections  not 
peculiar  to  the  anal  region,  such  as  eczema,  sebaceous 
cysts,  warts,  and  ulcers  of  various  kinds,  require  no 
special  mention.  Condylomata  are  usually  easily 
recognised  as  flat-topped,  moist,  slight  raised  granulo- 
mata  situated  near  the  anus  rather  than  actually  at  the 
orifice  itself,  and  often  lying  on  the  opposed  surfaces  of 
the  nates. 

The  external  orifice  of  a  fistula  may  present  as  an 
obvious  opening  discharging  pus.  More  often,  how- 
ever, it  is  concealed  partially  or  wholly  by  a  little  button 
of  granulation  tissue,  which  may  have  very  nearly  the 
colour  of  the  surrounding  skin,  and  which  resembles  a 


2  02  SURGICAL    DIAGNOSIS. 

little  j)imple  or  smooth  wart.  Upon  pushing  aside  this 
little  elevation  the  orifice  of  the  fistula  may  be  detected 
with  a  probe. 

An  abscess  may  be  recognised  by  the  ordinary  signs 
of  such.  It  may  not  be  possible,  however,  to  say 
whether  an  abscess  is  in  the  subcutaneous  tissue,  that 
is  comparatively  superficial,  or  whether  it  extends  deeply 
into  the  ischiorectal  region  by  the  side  of  the  rectum, 
until  an  internal  digital  examination  has  been  made. 

Careful  palpation  should  be  made  over  the  whole  of 
the  region  round  the  anus  to  detect  the  presence  of  indu- 
rated areas  which  may  indicate  the  presence  of  a  deep- 
seated  abscess,  or  of  the  burrowing  track  of  a  fistula 
(with  or  without  external  opening). 

The  swellings  which  appear  at  the  anus  itself  have 
already  been  described  (p.  199).  If  piles  are  detected, 
it  should  be  noticed  whether  they  are  inflamed,  ulcer- 
ated, gangrenous  or  thrombosed.  The  latter  condition  is 
recognised  by  the  hardness  of  the  pile.  External  piles  are 
known  by  the  little  folds  or  tags  of  skin  covering  them. 

If  internal  piles  are  present  but  not  prolapsed,  they 
may  sometimes  be  made  to  protrude  by  telling  the 
patient  to  strain  gently  downwards. 

Often  their  presence  cannot  be  detected  without  an 
internal  examination,  and  it  is  often  not  easy  to  detect 
them,  even  with  a  finger  in  the  rectum,  because,  when 
collapsed  and  empty,  they  do  not  present  the  same 
rounded  sensation  to  the  finger  as  they  do  when  pro- 
lapsed and  full  of  blood. 

If  the  symptoms  indicate  fissure,  the  anus  itself 
should  be  carefully  examined  after  separating  the 
margins  of  that  orifice.  It  is  at  the  posterior  part  of 
the  anus  that  a  fissure  is  most  commonly  found.     If 


DISEASES   OF   THE   RECTUM   AND   ANUS.       203 

piles  are  also  present,  a  fissure  is  often  found  under- 
lying and  partly  concealed  by  one  of  them. 

A  malignant  growth  at  the  anus  or  extending  into  the 
subcutaneous  tissues  is  generally  easily  recognised  by  its 
extreme  hardness.  If  any  doubt  exist,  a  small  portion 
may  be  snipped  off  and  examined  with  the  microscope. 

In  the  examination  of  the  interior  of  the  rectum  the 
finger  alone  is  usualty  sufficient.  A  probe,  bougie  or 
speculum  may  also  be  useful  in  certain  cases.  Care 
should  be  taken  to  introduce  the  finger  gently  and 
slowly,  and  it  should  be  well  lubricated,  so  that  it  slips 
in  easily.  In  some  cases  of  very  painful  affections  of 
the  anus  such  as  fissure,  it  may  be  well  to  defer  the 
digital  examination  until  the  patient  is  under  the 
influence  of  an  anaesthetic.  Normally  the  interior  of 
the  rectum  should  have  a  smooth,  velvety  feel.  Any 
departure  from  this  velvety  sensation  indicates  disease, 
generally  ulceration. 

The  investigator  should,  of  course,  be  thoroughly 
familiar  with  what  he  ought  to  be  able  to  feel  when 
examining  a  normal  rectum.  A  beginner,  for  example, 
sometimes  mistakes  the  normal  cervix  uteri  for  a 
tumour.  The  internal  opening  of  a  fistula  may  present 
as  a  small  opening  or  a  little  prominence  or  a  little 
rough  patch  on  the  otherwise  smooth  mucous  mem- 
brane. Perhaps  the  best  guide  to  the  existence  of  a 
fistula  is  the  indurated  track  that  can  be  felt  beneath 
the  mucous  membrane.  Such  an  induration,  however, 
does  not  necessarily  show  that  any  internal  opening  is 
present.  If  there  is  an  external  opening  a  probe  may 
be  passed  into  it  and,  guided  by  the  finger  in  the 
rectum,  it  may  then  be  passed  on  through  the  internal 
opening  into  the  rectum  itself.     Beginners  often  over- 


204  SURGICAL    DIAGNOSIS. 

look  the  existence  of  tlie  internal  opening  of  a  fistula, 
because  they  begin  their  examination  too  high  up  in 
the  rectum.  Most  fistulae  have  their  internal  openings 
close  to  the  anus,  between  the  external  and  internal 
sphincter  muscles. 

In  some  cases  the  internal  opening  of  a  fistula  may 
be  more  easily  detected  by  injecting  some  fluid  such  as 
ink  or  milk  through  the  external  opening,  and  seeing, 
with  the  help  of  a  speculum,  the  escape  of  the  fluid 
through  the  internal  opening. 

A  stricture  of  the  rectum  is  easily  detected  if  within 
reach  of  the  finger.  If  not  quite  within  reach,  it  may 
sometimes  be  brought  down  a  little  by  bimanual 
examination,  the  hand  on  the  hypogastrium  pressing  the 
pelvic  contents  downwards  till  the  stricture  is  brought 
into  contact  with  the  tip  of  the  examining  finger. 
Straining  on  the  part  of  the  patient  may  also  succeed 
in  bringing  the  stricture  within  reach  of  the  finger. 
Examining  the  patient  while  he  is  standing  up  may  also 
produce  a  similar  result. 

Cancer  in  its  early  stage  may  present  itself  as  a  small 
hard  sessile  mass  with  a  well-defined  outline.  When 
ulcerated,  it  is  the  hard  edge  of  the  ulcer,  showing  the 
presence  of  actual  new  growth,  that  is  of  most  value  in 
the  diagnosis.  It  must  be  admitted  that  occasionally 
simple,  syphilitic  or  tuberculous  ulcers  are  surrounded 
by  much  hard  inflammatory  tissue,  which  may  closely 
resemble  the  infiltration  of  new  grow^th. 

The  presence  of  hard  glands  in  the  pre-sacral  tissue 
may  afford  valuable  aid  in  the  diagnosis  of  malignancy. 

Stricture  of  the  rectum  may  be  of  the  so-called 
annular  variety,  involving  but  a  short  length  of  the 
rectum,   or   may  be  tubular,  involving  a  considerable 


DISEASES    OF    THE    RECTUM    AND    ANUS.       205 

length.  The  upper  edge  of  a  carcinomatous  growth, 
or  of  a  stricture  of  any  kind  through  which  the  finger 
cannot  be  passed,  may  sometimes  be  defined  in  the 
case  of  women  by  examining  per  vaginam. 

In  any  case  of  malignant  disease  an  attempt  should 
be  made  not  merely  to  determine  its  malignant  nature, 
but  also  to  ascertain  its  exact  extent,  its  degree  of 
fixity,  and  the  extent  to  which  it  has  involved  the 
surrounding  parts  and  the  lymphatic  glands. 

Congenital  malformations  of  the  rectum  fall 
naturally  into  three  groups  : 

1.  Imperforate  anus  proper,  in  which  there  is  either 
no  trace  of  an  anus,  or  the  latter  is  represented  by  a 
mere  dimple.  In  these  cases  it  is  important  to  notice 
whether  there  is  any  bulging  of  the  anal  region  when 
the  child  cries.  If  there  is,  it  may  be  presumed  that 
the  lumen  of  the  rectum  is  not  far  away. 

2.  Imperforate  rectum,  in  which  the  occlusion  is 
above  the  anus,  the  latter  being  well  formed.  The 
occlusion  may  be  of  any  degree,  from  an  incomplete 
partition  like  a  diaphragm  across  the  rectum,  up  to  the 
condition  in  which  a  considerable  length  of  rectum  is 
wholly  absent.  Cases  of  imperforate  rectum  are  not  so 
easily  recognised  as  those  of  imperforate  anus,  since  the 
diagnosis  is  not  made  until  a  finger  has  been  inserted 
through  the  anus. 

3.  The  third  group  of  cases  is  that  in  which, 
together  with  a  malformation  of  the  rectum,  there 
is  an  abnormal  fistulous  communication  with  the 
genital  organs,  most  commonly  the  vagina.  In  such 
cases,  if  the  fistulous  opening  be  large,  the  malforma- 
tion may  not  attract  attention  until  the  child  has  passed 
well  beyond  the  period  of  infancy. 


CHAPTER   XX. 

DISEASES  OF  THE   URINARY  ORGANS. 

In  the  investigation  of  a  case  of  supposed  disease  of  the 
urinaiy  organs  we  shall  do  well  to  direct  our  attention, 
as  regards  both  history  and  physical  examination,  to  the 
following  four  points  : 

I.  Signs  and  symptoms   connected  with   diminution 
of  the  normal   excreting  power  of  the  urinary 
organs  (kidneys). 
II.  Alterations  in  the  manner  in  which  the  urine  is 
voided  from  the  body. 

III.  Alterations  in  the  constituents   and  character  of 

the  urine. 

IV.  Physical   examination    of    the    various    urinary 

organs     (kidney,     ureter,      bladder,     prostate, 
urethra). 

I.  Signs  and  Symptoms  connected  with 

Diminution  of  the  Normal  Excreting  Power 

of  the  Urinary  Organs  (Kidneys). 

The  subject  of  chronic  renal  disease  often  presents 
a  pale  sallow  appearance  ;  there  is  a  tendency  to  oedema, 
especially  of  the  eyelids  and  ankles.  He  is  apt  to  be 
languid  and  disinclined  to  exert  himself  actively.     The 


DISEASES    OF   THE   URINARY   ORGANS.       207 

arteries  generally  may  be  hard  and  show  high  tension, 
or  they  may  be  distinctly  atheromatous.  Hypertrophy 
of  the  left  ventricle,  often  associated  with  chronic  renal 
disease,  may  point  in  the  same  direction.  So  may  reti- 
nitis. In  the  later  stages  of  actual  uraemia  drowsiness, 
twitchings  and  other  well  known  symptoms  may  occur. 

TJraBmia. — It  is  convenient,  however,  to  divide 
the  clinical  symptoms  of  what  is  commonly  called 
urasmia  into  three  groups,  which  depend  upon  different 
conditions  of  renal  inadequacy.  A  normal  person  pos- 
sesses much  more  renal  tissue  than  is  actually  required 
for  the  purpose  of  excreting  his  waste  products.  This 
quantity  may  be  gradually  or  even  suddenly  reduced  by 
disease  or  injury,  and  yet  the  patient  is  able  to  live.  But 
if  the  total  amount  of  secreting  renal  tissue  is  reduced 
below  a  certain  minimum,  which  has  been  estimated  at 
half  one  normal  kidney,  then  the  condition  becomes  in- 
compatible with  life,  and  the  patient  dies  of  urasmia. 

The  three  clinical  types  are — 

1.  That  in  which  the  patient's  kidneys  are  both 
more  or  less  suddenly  thrown  out  of  work  as  the 
result  of  acute  inflammation.  These  patients  show 
anasarca,  and  drowsiness  deepening  into  coma  ;  they 
have  twitchings  or  convulsions,  vomit,  and  pass  small 
quantities  of  urine,  which  contains  blood,  and  is 
loaded  with  albumen  and  casts. 

2.  A  second  type  is  that  in  which,  although  there  may 
be  plenty  of  renal  tissue,  for  some  reason  or  other  the 
urine  cannot  be  excreted.  It  is  reabsorbed  into  the 
circulation,  and  the  patient  dies  poisoned  by  his  own 
urinary  secretion.  Such  a  patient  presents  for  several 
days  few  or  no  symptoms  of  disease  except  anuria ; 
then  rather  suddenly  he  becomes  profoundly  weak,  and 


2  08  SURGICAL    DIAGNOSIS. 

has  muscular  tremor,  panting  respiration,  anorexia, 
insomnia,  and  often  pin-point  pupils.  The  temperature 
steadily  falls  below  normal.  The  patient  dies  of  sheer 
exhaustion  without  convulsions  or  coma. 

This  condition  is  seen  in  cases  of  calculi  com- 
pletely blocking  both  ureters,  and  in  those  unfortunate 
surgical  cases  in  which  a  solitary  kidney  has  been 
removed,  or  both  ureters  have  been  accidentally  tied 
in  the  course  of  an  operation.  Prompt  removal  of  the 
calculus  or  other  obstruction  relieves  the  symptoms. 

3.  The  third  type  is  that  to  which  the  name  of 
"  renal  bankruptcy "  has  very  appropriately  been 
applied.  It  is  best  seen  in  cases  of  gradual  destruction 
of  both  kidneys,  generally  by  backward  pressure  from 
an  obstruction  in  the  urethra,  such  as  an  enlarged 
prostate.  The  valency  of  the  renal  tissue  is  gradually 
reduced  without  the  production  of  marked  symptoms, 
until  the  point  is  approached  at  which  life  can  no 
longer  be  supported.  Then  wasting  and  anaemia, 
morning  vomiting,  great  thirst,  creamy  tongue,  and 
panting  respiration  set  in ;  the  urine  is  plentiful  in 
amount,  but  of  low  specific  gravity  (under  10 1 o), 
with  very  little  urea,  and  usually  only  a  trace  of  albu- 
men and  a  few  casts.  A  practical  point  of  importance 
is  that  the  passage  of  a  catheter  in  such  a  patient  will 
frequently  precipitate  the  catastrophe,  and  the  patient 
will  die  within  a  week,  no  treatment  being  of  any  avail. 

Sepsis  plays  a  very  important  part  in  the  production 
of  uraemia.  A  patient  whose  renal  tissue  has  gradually 
been  reduced  by  disease  (e.g.,  atrophy  from  backward 
pressure),  nearly  to  the  ])oint  of  bankruptcy,  may  still 
be  able  to  get  about  and  do  his  ordinary  work,  and  may 
appear  to  be  in  fairly  good  general  health.  The  urinary 


DISEASES    OF   THE   URINARY   ORGANS.       209 

organs  are  still  aseptic.  But  let  a  septic  element  be 
introduced  (as  by  tlie  passage  of  a  catheter  in  a  case  of 
chronic  enlargement  of  the  prostate),  and  acute  symp- 
toms at  once  set  in.  The  residue  of  renal  tissue, 
hitherto  just  sufficient  to  carry  on  its  work  of  excretion, 
is  now  unable  to  do  so  when  hampered  by  the  extra 
strain  of  septic  inflammation.  It  breaks  down  alto- 
gether, and  urgemia  manifests  itself. 

II.  Alterations  in  the  Manner  of  voiding 
Urine  from  the  Body. 

1.  Frequency  of  micturition  may  be  due  to 
increase  in  the  total  quantity  of  urine  secreted,  as  in 
diabetes  and  some  cases  of  chronic  albuminuria  as  above 
mentioned. 

More  often,  however,  frequency  of  micturition  means 
some  irritation  about  the  bladder,  prostate  or  urethra, 
producing  a  desire  to  micturate.  The  irritation  of 
cystitis,  of  calculus  in  the  bladder,  of  enlargement  of 
the  prostate  or  of  stricture  of  the  urethra,  afford  familiar 
examples.  Although  micturition  is  frequently  per- 
formed, the  amount  of  urine  passed  each  time  is  small. 

Marked  frequency  of  micturition  by  day  and  when 
the  patient  is  moving  about  suggests  a  calculus  in  the 
bladder.  The  movement  of  the  stone  causes  increased 
irritation  of  the  neck  of  the  bladder. 

Increased  frequency  at  night,  when  the  patient  is  warm 
in  bed  and  the  pelvic  viscera  are  apt  to  be  congested, 
is  especially  common  in  cases  of  enlarged  prostate. 

2.  Painful  micturition  (dysuria). — Painful  mic- 
turition usually  means  some  inflammatory  trouble  in  the 
urethra,  prostate,  or  bladder. 

o 


2  10  SURGICAL   DIAGNOSIS. 

An  inflamed  urethra  or  an  ulcerated  spot  in  connection 
with  a  stricture  may  cause  a  sharp  cutting  pain  along 
the  urethra  during  the  act  of  micturition. 

Inflammation  or  ulceration  about  the  neck  of  the 
bladder  (vesical  orifice  of  the  urethra)  usually  causes  a 
pain  that  is  referred  to  the  end  of  the  penis,  often  to  a 
point  just  behind  the  under  surface  of  the  glans.  Such 
is  the  well-known  pain  caused  by  a  calculus  when  it  is 
driven  against  the  tender  and  perhaps  ulcerated  vesical! 
orifice  of  the  urethra.  Tuberculous  or  other  ulceratioio 
in  this  situation  may  produce  exactly  the  same  kind  of 
pain.  So  it  happens  that  calculus  of  the  bladder  is 
easily  simulated  by  tubercle. 

The  pain  of  cystitis  is  more  difi'used,  being  felt  about 
the  pelvic  region  generally,  in  the  hypogastrium  and 
perinasum  and  down  the  thighs.  It  is  especially  marked 
just  at  the  commencement  of  micturition,  owing  to  the 
extra  tension  present  at  this  moment  in  the  tender  and 
inflamed  bladder  wall. 

The  greatest  amount  of  dysuria  may  be  expected  in  a 
case  in  which  there  is  acute  inflammation  about  the  neck 
of  the  bladder,  plus  an  obstruction  (e.g.,  inflamed  or 
ulcerated  prostate,  simple  or  malignant). 

3.  Alterations  in  the  character  of  the 
stream  of  urine. — Given  a  normal  outlet  for  the 
urine  by  the  urethra  and  a  normal  propulsive  power  in 
the  bladder  wall,  the  uriae  is  propelled  forcibly  in  a 
good  stream. 

Any  obstruction  to  the  outflow  or  any  failure  in 
vesical  expulsive  power  causes  the  stream  to  be  lacking 
in  projection. 

Atony  of  the  bladder  from  over  distension  is  an 
example   of   the  former,   stricture   of   the   urethra  or 


DISEASES    OF   THE   URINARY   ORGANS.       211 

enlargement  of  the  prostate,  afford  good  examples 
of  the  latter.  The  urine,  instead  of  being  projected 
forwards  in  a  good  stream,  tends  to  fall  directly  down- 
wards from  the  urethral  orifice,  or  may  merely  dribble 
away. 

The  character  of  the  stream  in  other  respects  is  of 
little  importance.  A  small  stream  with  good  projection 
is  seen  only  in  cases  of  stricture  at  or  close  to  the  meatus 
urinarius.  A  twisted  or  forked  stream  may  be  caused 
by  a  stricture  in  the  same  situation,  but  is  not  seen 
when  the  stricture  is  further  back  in  the  urethra. 

III.  Alterations  in  the  Character  and 
Constituents  of  the  Urine. 

This  is  such  a  large  subject  that  it  can  only  be  dealt 
with  briefly.  For  full  details  some  of  the  larger  well- 
known  text-books  must  be  consulted. 

The  total  quantity  of  urine  that  is  passed  often 
affords  valuable  indications  of  disease. 

To  obtain  reliable  information  on  this  point,  all  the 
urine  passed  during  each  period  of  twenty-four  hours 
must  be  collected  and  measured  regularly.  The  quantity 
is  influenced  partly  by  the  amount  of  fluid  imbibed  by 
the  patient,  partly  by  the  presence  of  diseases  such  as 
diabetes  or  nephritis,  partly  by  nervous  influence  such 
as  hysteria  ;  partly  also  by  diuretic  medicines.  A  large 
quantity  of  urine  is  passed  by  patients  with  diabetes  ; 
in  this  case  the  urine  will  have  an  abnormally  high 
specific  gravity. 

A  large  quantity  of  urine  with  a  low  specific  gravity 
generally  indicates  either  chronic  nephritis,  multiple 
cystic  disease  of  the  kidneys,  or  hysteria ;  a  temporary 


2  12  SURGICAL   DIAGNOSIS. 

increase  in  the  amount   of  urine   may  be  caused  by 
emotional  conditions  such  as  fright  or  nervousness. 

The  specifiLc  gravity  of  the  urine  is  of  great 
importance  as  indicating  the  amount  of  solid  con- 
stituents dissolved  in  the  urine.  It  must  be  considered 
in  relation  to  the  total  quantity.  A  high  specific  gravity 
may  mean  nothing  more  than  a  concentrated  but  other- 
wise normal  urine.  A  high  specific  gravity  (over  1025) 
should  always  lead  the  observer  to  examine  for  sugar. 
A  persistently  low  specific  gravity  (under  1015)  should 
generally  raise  the  suspicion  of  chronic  nephritis  with 
atrophy  of  the  secreting  tissue  of  the  kidneys.  Eoughly, 
the  specific  gravity  of  the  urine  is  an  indication  of  the 
amount  of  excreting  tissue  in  the  kidneys. 

The  amount  of  urea  present  in  the  urine  passed 
during  a  period  of  twenty-four  hours  is,  however,  the 
best  guide  to  the  condition  of  the  kidneys  as  regards 
their  excreting  power.  Mucus  in  small  quantity  is 
normal,  but  a  large  quantity  of  mucus  indicates  inflam- 
mation of  the  mucous  membrane  of  the  bladder  (cystitis). 

The  colour  of  the  urine  depends  largely  upon  its 
concentration.  Dilute  urine  is  naturally  pale.  The 
colour  is  also  influenced  greatly  by  the  presence  in  it  of 
such  abnormal  substances  as  bile,  blood,  pus,  and  various 
drugs,  such  as  carbolic  acid. 

Urinary  deposits.  —  Urine  which  on  cooling 
deposits  a'brick-red  or  salmon-coloured  sediment,  which 
clears  away  on  heating,  contains  urates.  A  deposit 
which  comes  down  on  boiling,  and  then  disappears  on 
the  addition  of  a  drop  or  two  of  acetic  acid,  usually 
indicates  phosphates. 

Crystals  in  the  urine  may  be  visible  to  the  naked 
eye  in  the  form  of  small  reddish  grains  like  cayenne 


DISEASES    OF    THE    URINARY    ORGANS.       213 

pepper  (uric  acid) ;  more  often  they  are  visible  only 
with  the  microscope.  The  three  commonest  forms  are 
uric  acid,  oxalate  of  lime,  and  triple  phosphate,  each 
having  a  characteristic  shape.  The  two  former  may  point 
to  a  calculus  in  the  kidney,  the  latter  generally  indicates 
cystitis,  and  is  due  to  the  splitting  up  of  urea  under  the 
influence  of  micro-organisms. 

The  most  important  abnormal  constituents  of  urine 
are  blood,  pus,  albumen,  bacteria  and  sugar.  The 
two  former, although  readily  recognisable  with  the  naked 
eye,  when  present  in  sufficient  quantity, are  best  detected 
by  means  of  the  microscope.  This  is  far  superior  to 
any  of  the  chemical  tests  commonly  employed. 

The  clinical  importance  of  blood  and  pus  in  the  urine 
is  so  great  that  the  following  chapter  will  be  devoted  to 
their  consideration.  Albumen  and  sugar  are  readily  re- 
cognisable by  well-known  teats  which  need  not  be  given 
in  detail  here.  The  first  is  recognised  by  the  precipitate 
formed  on  boiling,  which  does  not  clear  up  on  the  addition 
of  a  drop  of  acid;  or  by  its  behaviour  with  cold  nitric  acid 
or  with  picric  acid.  Sugar  is  usually  detected  by  its  power 
of  reducing  copper  oxide  from  a  solution  of  the  sulphate. 

Hydatid  cysts,  or  hooklets,  the  ova  of  Bilharzia, 
shreds  of  vesical  or  renal  epithelium,  bits  of  villous 
growth,  and  other  extraneous  matter  seen  with  the 
naked  eye  or  with  the  microscope,  may  afford  valuable 
clues  to  the  nature  of  the  disease  from  which  the 
patient  is  suffering. 

Bacteria  may  obtain  entrance  to  the  urine  from 
within  from  the  blood  stream,  as  in  tuberculous  disease 
of  the  kidney.  Far  more  commonly,  however,  they  are 
introduced  into  the  urine  directly  from  without,  most 
often   through   the   medium  of   instruments.     In  the 


214 


SURGICAL    DIAGNOSIS. 


former  case  the  urine  remains  acid,  in  the  latter  the 
urine  decomposes  and  quickly  becomes  alkaline. 

I  am  indebted  to  Mr.  Harold  L.  Barnard  for  the  fol- 
lowing scheme  relating  to  the  bacteriology  of  the  urine. 


Urine. 


Acid. 


Alkaline. 


Micro-organ- 
isms. 


Origin. 


Effects 


Appearance 
of  urine. 


Calculi. 
Symptoms. 


Treatment. 


Bacillus  coli  communis. 
B.  tj^Dhosus. 
B.  tuberculosis. 


Usually  from  the  circulation 
through  the  kidney — ab- 
sorbed from  alimentary 
canal  (in  constipation 
and  inflammatory  condi- 
tions). 

Do  not  decompose  urea. 


Cloudiness  due  to  bacteria 

and  epithelial  cells. 
Little  or  no  smell. 
Decomposes  slowly. 
Settles  quickly. 

Eroded  and  broken  up. 

Burning  during  and  at  the 
end  of  micturition.  Fre- 
quency of  micturition. 

Enuresis  in  children. 

Periodical  attacks. 


1.  Calomel. 

2.  Diluents. 
Salol. 
Urotropine 

only). 


(typhoid 


Staphylococcus. 
Streptococcus. 
Micrococcus  urese. 
Bacilli  of  various  kinds. 

From  the  urethra  as  the 

result  of  retention. 
Instrumentation. 


Decompose  urea. 

Calcium  and  magnesium 
phosphates  are  thrown 
down  as  triple  phos- 
phates. (Sodium  and 
potassium  phosphates 
not  thrown  down. ) 

Heavy   deposit    of   pus, 
phosphates  and  mucus. 
Foul  smell. 
Decomposes  rapidly. 
Settles  slowly. 

Added  to  by  phosphates. 

Those  of  ordinary  acute 

cystitis. 


1.  Remove  obstruction. 

2.  Urotropine  and   acid 

sodium  phosphate 
very  effective. 

3.  Irrigate  or  drain. 


DISEASES    OF    THE    URINARY    ORGANS.       215 

IV.   Physical   Examination    of   the    Urinary 
Organs  (kidney,  ureter,  bladder,  prostate,  urethra). 

Kidney. — The  physical  examination  and  the  char- 
acter of  an  enlarged  kidney  have  already  been  discussed 
in  chap.  x.iv.  (p.  151).  The  diagnosis  of  the  nature  of 
the  enlargement  is  generally  made  from  the  presence  of 
other  signs  and  symptoms. 

Very  great  enlargement  usually  means  either  malig- 
nant disease  or  hydronephrosis. 

Pyonephrosis  does  not  often  attain  to  a  size  larger 
than  that  of  a  cocoanut,  but  a  much  larger  swelling  may 
be  formed  when  a  pyonephrosis  has  leaked  and  set  up 
a  perinephric  abscess  (abscess  outside  the  kidoey). 

In  these  cases  the  characteristic  shape  of  the  kidney 
is  usually  wholly  obscured.  Suppurative  conditions  of 
the  kidney  are  apt  to  cause  fixity  of  the  organ  to  sur- 
rounding parts,  if  the  suppuration  or  inflammation  have 
spread  beyond  the  limits  of  the  kidney  capsule. 

Thus  a  simple  hydronephrosis  of  moderate  size  may 
sometimes  be  diagnosed  by  its  smoothness  and  mobility 
from  a  tuberculous  kidney.  X-rays  may  be  of  much 
value  in  the  detection  of  stones  of  moderate  and  large 
size. 

Exploratory  operation  from  the  loin  or  from  the  front 
is  often  necessary  before  the  exact  nature  of  a  renal 
swelling  can  be  determined. 

In  exploring  a  kidney  for  stone,  careful  palpation 
should  be  made,  especially  at  its  pelvis  and  along  the 
ureter. 

If  it  be  deemed  desirable  to  open  the  kidney  to  search 
for  a  stone,  this  may  be  done  with  least  hgemorrhage  by 
splitting  the  kidney  vertically  along  its  outer  or  convex 


2l6  SUHGICAL    DIAGNOSIS. 

border.     The  interior  of  the  pelvis  and  the  ureter  can 
then  be  thoroughly  explored  by  finger  or  sound. 

A  stone  impacted  in  the  lower  part  of  the  ureter  may 
be  detected  by  a  probe  passed  down  to  it  from  the 
renal  pelvis. 

Ureter. — The  examination  of  the  ureter  may  be 
made  in  several  ways.  The  vesical  orifice  can  be  seen 
with  cystoscope  or  endoscope.  The  intra-abdominal 
portion  of  the  ureter  can  occasionally  be  felt  through 
the  abdominal  wall  if  the  patient  is  thin  and  the  ureter 
much  thickened,  as  in  chronic  tuberculous  disease. 

The  ureter  can  easily  be  exposed  and  examined  by 
sight  and  touch  by  a  long  incision  carried  from  the  loin 
round  to  the  groin,  above  the  crest  of  the  ilium.  The 
abdominal  muscles  and  transversalis  fascia  are  divided, 
and  the  peritoneum  and  viscera  drawn  inwards  and 
forwards.  The  upper  part  of  the  pelvic  portion  of  the 
ureter  can  be  exposed  by  a  similar  operation,  or  by  an 
abdominal  section,  the  peritoneum  being  incised  directly 
over  the  ureter. 

The  lower  part  of  the  ureter  can,  in  the  female  subject, 
be  palpated  directly  from  the  vagina  at  its  upper  and 
anterior  part.  Thickening  of  the  ureter  from  chronic 
inflammation  or  the  presence  of  a  calculus  may  be 
detected  in  this  way. 

The  interior  of  the  ureter  may  be  examined  by 
sounding  or  by  catheterisation.  The  proceedings  require 
some  little  skill  and  practice,  and  are  much  more  easy 
to  perform  in  women  than  in  men.  The  utmost  care 
must  be  taken  not  to  introduce  septic  matter  into  the 
ureter  during  the  introduction  of  the  instruments.  In 
women  the  passage  of  instruments  into  the  ureter  is 
most  conveniently  effected  with  the  patient  in  the  genu- 


DISEASES    OF    THE    URINARY    ORGANS.       217 

pectoral  position,  a  Kelly's  endoscope  being  introduced 
into  the  air-containing  bladder,  and  a  forehead  mirror 
being  worn  by  the  operator. 

Sounding  of  the  ureter  is  employed  for  the  detection 
(and  occasionally  for  the  dilatation)  of  a  stricture,  or  for 
the  detection  of  a  calculus  in  the  ureter  or  pelvis  of  the 
kidney.  For  the  latter  purpose  it  is  convenient  to  use 
a  bougie  coated  with  wax,  upon  which  the  rough  stone 
will  leave  an  impression. 

Oatheterisation  of  the  ureters  is  employed  not  for  the 
detection  of  disease  of  the  ureter  itself,  but  for  drawing 
off  urine  from  the  kidney,  and  so  for  investigating  the 
condition  of  that  organ. 

It  is  of  especial  importance  as  affording  a  means  of 
comparing  the  secretion  of  the  two  kidneys.  The 
amount  of  urine  that  can  be  drawn  off  by  catheterising 
the  ureter  gives  some  idea  of  the  degree  of  dilatation  of 
the  ureter  or  pelvis  of  the  kidney  in  a  case  of  obstruc- 
tion in  the  ureter. 

Bladder. — The  bladder  may  be  examined  both 
from  without  (per  hypogastrium,  per  rectum,  or  per 
vaginam)  and  from  within. 

Bimanual  examination  is  often  useful  in  the  detection 
of  calculi  (especially  in  children),  and  in  the  detection 
of  carcinomatous  growths  of  considerable  size,  especially 
when  situated  at  the  base  of  the  bladder. 

From  within,  the  bladder  may  be  examined  by  sight 
by  means  of  the  endoscope  or  cystoscope  or  by  explora- 
tory cystotomy  (suprapubic)  ;  by  palpation  with  the 
sound  ;  or,  after  exploratoiy  cystotomy  (suprajDubic  or 
perineal),  with  the  finger. 

Valuable  information  may  also  be  obtained  by  means 
of  the  catheter,  not  only  as  regards  the  nature  of  the 


2l8  SURGICAL    DIAGNOSIS. 

fluid  contained  within  it,  but  also  as  regards  its  quantity 
— i.e.,  the  capacity  of  the  bladder. 

Prostate. — Physical  examination  of  the  prostate  is 
made  chiefly  by  means  of  a  finger  in  the  rectum  ;  it  is 
also  made  from  within  from  the  urethral  aspect  by 
means  of  the  sound,  bougie,  catheter,  or  cystoscope. 
Occasionally  the  examination  is  made  from  within 
the  bladder  through  a  cystotomy  wound  by  sight  or 
touch. 

Examination  per  rectum. — Simple  inflammation 
of  the  prostate  shows  enlargement  and  tenderness. 
A  soft  spot  may  reveal  the  presence  of  a  localised 
abscess.  In  some  cases  a  considerable  area  of  softness 
obscuring  the  normal  outline  of  the  prostate  may 
indicate  an  abscess  of  considerable  size  burrowing 
outside  that  organ  between  it  and  the  rectum. 

Tuberculous  inflammation  is  shown  by  enlargement, 
and  often  by  hardness  and  irregularity ;  sometimes  by 
areas  of  softening  when  the  tuberculous  deposits  have 
broken  down.  The  examination  of  the  vesiculee  semi- 
nales  is  of  much  importance  in  the  diagnosis  of  tubercle, 
since  they  are  usually  large  and  hard  in  this  disease  on 
one  or  both  sides.  Calculi,  if  sufficiently  near  the 
surface,  may  be  detected  by  their  extreme  hardness. 
They  are  often  multiple,  and  it  is  sometimes  possible  to 
elicit  a  most  characteristic  grating  sensation,  caused  by 
the  calculi  rubbing  one  against  another. 

Malignant  disease  (especially  carcinoma,  the  com- 
monest form)  can  generally  be  recognised  with  ease  by 
the  extreme  hardness,  the  nodularity  of  the  growth, 
and  often  by  its  fixity.  Often  the  growth  can  be  felt 
to  infiltrate  the  neighbouring  parts  of  the  bladder  and 
vesiculsB  seminales. 


DISEASES    OF    THE    URINARY    ORGANS.       219 

The  urethral  aspect  of  the  prostate  is  examined  by 
means  of  sound,  bougie,  or  catheter,  which  indicate  an 
obstruction  at  this  part  of  the  urethra.  True  stricture 
of  the  urethra,  although  very  common  in  the  mem- 
branous urethra,  and  at  any  point  anteiior  to  this, 
practically  does  not  occur  in  the  prostatic  urethra. 
An  obstruction  to  the  prostatic  urethra  consequently 
means  either  a  prostate  enlarged  from  inflammation, 
simple  hypertrophy  or  growth  (adenoma  or  malignant 
disease)  ;  or  it  may  be  due  to  the  lodgment  of  a  foreign 
body  such  as  a  stone  within  the  prostatic  urethra.  The 
use  of  a  metallic  instrument  will  readily  indicate  the 
presence  of  a  calculus. 

The  manner  in  which  a  sound  or  catheter  passes 
through  the  prostate  may  afford  some  indication  of  the 
nature  of  the  disease. 

Thus  deflection  of  the  point  of  the  instrument  to  one 
or  other  side  means  either  that  the  whole  prostate  has 
been  pushed  aside  as  by  a  growth  outside  it,  or  more 
often  it  indicates  irregular  enlargement,  as  in  the 
common  senile  adenomatous  enlargement  of  the  organ. 

An  instrument  which  can  be  made  to  enter  the 
bladder  only  after  unusual  depression  of  the  handle 
indicates  enlargement  of  the  middle  lobe  over  which 
the  point  of  the  instrument  has  to  be  raised.  The 
facility  with  which  a  coudee  catheter  enters  the 
bladder  in  such  a  case  also  points  in  the  same  direction. 

The  presence  of  an  enlarged  middle  lobe,  or  of  a  bar 
at  the  neck  of  the  bladder  in  senile  enlargement  of  the 
prostate,  may  also  be  detected  by  means  of  the  cysto- 
scope. 

Urethra. — This  may  be  examined  from  without  by 
inspection   and   palpation,  or   from  within  either  by 


2  20  SURGICAL    DIAGNOSIS. 

inspection  with  a  urethroscope,  or  much  more  com- 
monly by  palpation  by  means  of  a  sound,  bougie,  or 
catheter. 

The  urethra,  from  its  close  proximity  to  the  under 
surface  of  the  penis,  readily  permits  of  digital  palpa- 
tion along  its  whole  length.  Induration  about  a 
stricture,  abscess,  or  impacted  stone  may  thus  readily 
be  felt.  In  young  children  a  stone  impacted  at  the 
anterior  end  of  the  urethra  often  causes  an  acute 
oedema  of  the  prepuce,  while  at  the  same  time  the 
swelling  thus  produced  causes  the  stone  to  be  less 
easily  felt. 

The  perineal  region  should  alwaj^s  be  carefully 
palpated  in  connection  with  supposed  disease  of  the 
urethra,  since  it  is  here  that  abscesses  connected  with 
inflammatory  disease  of  the  urethra  are  especially  apt 
to  occur.  A  deep-seated  abscess  in  the  perineum,  con- 
nected with  stricture,  often  presents  itself  in  the  form 
of  an  exceedingly  hard,  well-defined  swelling,  which  to 
the  uninitiated  may  not  suggest  the  presence  of  pus. 

The  examination  of  the  interior  of  the  urethra  is 
usually  made  with  sound,  bougie,  or  catheter,  which 
enables  the  observer  to  localise  and  measure  any 
narrowing  that  there  may  be. 

By  means  of  a  metallic  instrument,  an  impacted 
calculus  may  be  detected.  The  urethroscope  may 
afford  useful  information  by  revealing  the  face  of  a 
stricture,  the  presence  of  ulceration,  &c.,  but  it  is  an 
instrument  of  far  less  value  than  the  corresponding  one 
which  is  employed  for  the  inspection  of  the  bladder. 


CHAPTER  XXI. 

PYURIA  AND  HiEMATURIA. 

The  occurrence  of  pus  or  blood  or  both  in  the  urine 
either  alone  or  in  combination  with  other  signs  and 
symptoms  of  disease,  is  so  common  that  it  seems 
desirable  to  devote  a  chapter  to  the  consideration  of 
these  two  signs  of  disease.  Either  blood  or  pus  maybe 
derived  from  any  part  of  the  urinary  tract  from  the 
kidney  to  the  external  orifice  of  the  urethra,  or  may 
proceed  from  disease  primarily  outside  that  tract,  but 
opening  secondarily  into  it. 

Blood  in  the  urine  indicates  a  breach  of  surface 
in  some  part  of  the  mucous  membrane  of  the 
urinary  tract.  Such  a  breach  may  be  extremely 
minute,  as  in  the  case  of  haemorrhage  due  to  mere 
congestion  or  inflammation  of  the  mucous  membrane 
itself.  More  often  the  haemorrhage  is  derived  from 
a  larger  breach  of  surface,  such  as  an  ulcer  exposing 
small  or  even  large  blood-vessels.  Granulations  bleed 
readily,  especially  when  subjected  to  slight  injury,  such 
as  that  caused  by  the  contraction  of  the  bladder. 

The  vessels  of  a  new  growth  are  very  prone  to 
give  way  and  to  bleed  on  slight  provocation.  Papil- 
loma of  the  bladder,  carcinoma  of  the  bladder,  sarcoma 
of  the  kidney  are  familiar  examples  of  tumours  which 


222  SUBGICAL   DIAGNOSIS. 

often  cause  profuse  h^ematuria.  The  bleeding  that 
results  from  gross  mechanical  injury,  such  as  that  pro- 
duced by  the  introduction  of  some  instrument  (catheter) 
or  from  external  violence,  needs  no  further  mention. 

Pus  in  the  urine  may  be  derived  from  a  simple  in- 
flammation of  the  mucous  membrane,  as  in  the  earlier 
stages  of  gonorrhoea  for  example. 

When  in  considerable  quantity  it  generally  indicates 
an  ulcerated  condition  of  some  part  of  the  urinary  tract. 

The  urinary  organs  themselves  may  be  the  sole  cause 
of  the  suppuration,  or  the  pus  may  be  derived  from  an 
abscess  cavity  itself  outside  the  urinary  tract,  but 
opening  into  some  part  of  that  tract,  usually  the 
bladder.  The  occurrence  of  pyuria  in  connection  with 
caries  of  the  hip  or  spine  is  a  familiar  example. 

In  most  cases  of  either  pyuria  or  h^ematuria  we  shall 
do  well  to  consider  more  or  less  separately,  (i)  the 
situation  of  the  lesion,  i.e.^  from  what  part  of  the 
urinary  tract  the  pus  or  blood  is  derived ;  (ii)  the 
nature  of  the  lesion. 

(i)  Situation  of  the  Lesion  causing  pyuria  or 
hgematuria. 

Urethra. — When  pus  or  blood  in  quantity  are 
derived  from  the  urethra,  there  is  usually  but  little 
difficulty  in  determining  the  source  of  the  discharge. 
The  discharge  of  pus  or  blood  independently  of  the  act 
of  micturition  shows  that  the  urethra  is  the  seat  of  the 
lesion.  During  micturition  it  is  the  first  few  drops  of 
urine  alone  that  contain  the  abnormal  constituent,  the 
rest  of  the  urine  being  clear  or  nearly  so.  A  cutting 
pain  along  the  course  of  the  urethra  during  the  act  of 


PYURIA   AND    HEMATURIA.  223 

micturition  may  also  point  to  a  local  seat  of  inflam- 
mation. 

A  history  of  injury  to  the  urethra  either  from  the 
outside,  or  more  often  from  the  inside,  from  the  use  of 
some  instrument,  may  indicate  clearly  enough  the 
source  of  a  hsematuria. 

A  careful  examination  of  the  urethra  and  perineum 
both  from  the  outside,  and,  if  necessary,  from  the 
inside,  by  catheter,  bougie,  urethroscope  or  other  instru- 
ment, may  reveal  the  cause  of  a  pyuria  or  a  hsematuria. 
In  connection  with  the  urethra,  the  prostate  must 
not  be  forgotten.  Suppuration  in  the  prostate  often 
makes  its  way  into  the  prostatic  urethra  and  thence  to 
the  exterior.  Abscess  originating  outside  the  prostate, 
in  the  perineum  or  between  the  rectum  and  bladder, 
may  also  discharge  into  the  prostatic  or  other  part  of 
the  urethra.  The  importance  of  a  rectal  examination 
in  cases  of  obscure  pyuria  or  hsematuria  is  obvious. 

With  regard  to  pjmria  it  is  well  to  remember  that  a 
patient  may  wilfully  deny  the  existence  of  any  symp- 
tom or  history  pointing  to  disease  of  the  urethra.  The 
doubtful  origin  of  a  long-continued  slight  pyuria  has 
before  now  been  cleared  up  by  the  detection  of  a 
stricture  or  a  small  ulcer  of  the  urethra. 

In  the  case  of  women  it  is  well  to  remember  that 
blood  or  pus  in  the  urine  may  be  derived,  not  from  the 
urinary  tract  at  all,  but  from  the  vagina  or  even  uterus. 
Bladder. — Blood  or  pus  coming  from  the  bladder 
is  frequently  associated  with  definite  bladder  symp- 
toms, such  as  frequency  of  micturition,  pain  in  the 
perineum,  or  hypogastrium,  or  at  the  end  of  the  penis. 
Blood  or  pus  having  a  vesical  origin  is  nearly  always 
more  or  less  intimately  mixed  with  the  urine. 


2  24  SURGICAL   DIAGNOSIS. 

The  presence  of  clots  of  blood  in  the  urine  is  more 
often  seen  in  cases  of  vesical  than  of  renal  haemorrhage. 

If  the  vesical  lesion  which  causes  the  pyuria  or 
haemorrhage  is  associated,  as  it  so  often  is,  with  cystitis, 
the  presence  of  mucus  in  the  urine  and  other  signs  of 
cystitis  are  of  importance  in  the  diagnosis.  Alkalinity 
of  the  urine  and  the  presence  of  phosphatic  crystals 
usually  indicate  vesical  inflammation.  The  existence 
of  cystitis  does  not,  however,  f^^xclude  the  possibility  of 
the  pus  or  blood  being  derived  from  the  kidney. 

Direct  examination  of  the  bladder  with  the  sound 
or  cystoscope,  or  with  the  finger  in  the  rectum  may 
aid  in  the  diagnosis.  In  some  cases  even  an  ex- 
ploratory operation  (suprapubic  cystotomy)  may  be 
desirable. 

Ureter  and  kidney. — The  ureter  as  a  source  of 
pyuria  or  hsematuria  can  clinically  scarcely  be  distin- 
guished from  tlie  kidney.  In  some  few  cases,  however, 
other  evidence  of  disease  of  the  ureter,  such  as  the  pal- 
pation of  a  stone  impacted  in  its  lower  end,  may  indi- 
cate the  exact  situation  of  the  disease. 

The  kidney  is  probably  the  seat  of  the  disease  if  there 
is  distinct  enlargement  of  that  organ,  or  if  there  is 
characteristic  renal  pain. 

The  absence  of  any  evidence  of  disease  of  the  urethra 
or  bladder  may  point  to  the  kidney  as  the  seat  of  a 
pyuria  or  hsematuria.  The  presence  of  casts  in  the 
urine  naturally  indicates  disease  of  the  kidney. 

Long  filiform  clots  of  blood  indicate  that  these  have 
been  formed  in  the  ureter,  and  point  to  disease  of  the 
kidney. 

Actual  inspection  of  the  vesical  ends  of  the  ureters 
often  affords  clear  proof  not  only  that  the  blood  or  pus 


PYURIA    AND    HEMATURIA.  225 

comes  from  the  ureter  or  kidney,  but  also  of  the  side 
from  which  it  comes.  Inspection  of  the  ureters  may  be 
effected  either  by  the  electric  cystoscope  or  directly  by 
Kelly's  endoscope. 

(ii)  The  Nature  of  the  Lesion. 

This  may  be  conveniently  discussed  under  the  fol- 
lowing four  heads  :  (a)  Simple  inflammation.  (h) 
Tuberculous  disease,    (c)  Calculus,     (d)    New  growth. 

In  the  vast  majority  of  cases  the  presence  of  blood 
or  of  pus  in  the  urine  is  due  to  one  or  other  of  these 
four  classes  of  disease. 

Diseases  outside  the  urinary  tract,  such  as  pelvic 
abscess,  causing  pyuria  or  even  hasmaturia  by  extension 
to  the  urinary  tract,  need  not  be  further  discussed,  since 
their  diagnosis  depends  rather  upon  the  existence  of 
special  signs  and  symptoms  indicative  of  those  diseases. 

(a)  Simple  inflammation  of  the  kidneys  (nephritis 
and  pyelitis)  belongs  rather  to  the  domain  of  the  physi- 
cian than  to  that  of  the  surgeon.  The  existence  of 
general  symptoms  of  renal  disease,  together  with  the 
presence  of  albuminuria  and  casts,  are  generally  suffi- 
cient for  the  diagnosis  of  disease  of  the  kidney  sub- 
stance. 

Simple  pyelitis,  that  is  pyelitis  not  due  to  tubercle 
or  calculus,  generally  occurs  either  in  association  with 
nephritis  or  as  a  secondary  result  of  cystitis,  the  inflam- 
mation spreading  upwards  along  the  ureter  to  the 
pelvis  of  the  kidney. 

The  differential  diagnosis  of  a  simple  pyelitis  is  made 
partly  by  the  detection  of  a  cause  for  the  pyelitis, 
such  as  a  spinal  injury  or  disease,  or  the  existence  of  a 

P 


226  SURGICAL   DIAGNOSIS. 

previous  cystitis  ;  partly  by  the  absence  of  signs  pointing 
directly  to  tubercle  or  calculus. 

Simple  cystitis,  that  is  cystitis  not  due  to  tubercle, 
calculus,  or  new  growth,  is  due  to  bacterial  invasion, 
either  from  the  urethra,  as  in  a  case  of  gonorrhoea,  or 
from  surrounding  parts,  as  in  the  case  of  an  inflam- 
matory affection  spreading  through  the  wall  of  the 
bladder,  or  occasionally  from  inflammation  spreading 
downwards  along  the  ureter.  The  occurrence  of  cys- 
titis is  favoured  by  the  presence  of  certain  abnormal 
conditions  of  the  spinal  cord,  such  as  injury  or  inflam- 
matory diseases.  The  bladder,  thus  deprived  of  the 
normal  trophic  influences  exerted  upon  it  by  the  spinal 
cordj  readily  becomes  a  prey  to  bacterial  invasion. 

As  in  the  case  of  pyelitis,  the  differential  diagnosis 
of  a  cystitis  resolves  itself  into  ascertaining  the  cause 
of  the  cystitis.  A  cystitis  in  the  first  instance  should 
usually  be  regarded  as  a  symptom  of  some  other  dis- 
ease, and  should  be  looked  upon  as  a  primary  disease 
only  when  all  other  possible  primary  causes,  such  as 
foreign  body,  calculus,  tubercle,  new  growths,  and 
affections  of  the  spinal  cord,  have  been  carefully  con- 
sidered and  excluded. 

(h  and  c)  The  differential  diagnosis  between  tu- 
berculous and  calculous  disease  both  of  the 
kidney  and  of  the  bladder  often  presents  the  greatest 
difiiculties.  This  is  not  surprising  when  we  reflect 
that  in  both  cases  the  main  symptoms  are  those  of 
ulceration  of  the  kidney  or  bladder.  The  ulceration 
is  produced  in  the  one  case  by  the  breaking  down  of 
tuberculous  deposits  in  the  mucous  membrane  and 
submucous  tissues  in  the  other  by  the  mechanical 
injury  caused  by  the  rough  stone. 


PYURIA   AND   HEMATURIA.  227 

With  regard  to  the  pyuria  and  hsematuria  produced 
by  both  these  diseases,  it  may  be  stated  that  the  former 
is  more  characteristic  of  tubercle,  the  latter  of  calculus. 
Exceptions  are,  however,  not  uncommon.  A  large  stone 
lying  quietly  in  the  kidney  may  cause  profuse  pyuria  with 
little  or  no  hsematuria.*  On  the  other  hand,  in  excep- 
tional cases  of  tubercle  both  of  the  kidney  and  of  the 
bladder,  but  especially  of  the  former,  the  tuberculous 
process  may  extend  so  deeply  as  to  involve  vessels  of 
some  magnitude,  and  profuse  hasmaturia  may  ensue. f 

The  presence  in  the  urine  of  crystals  on  the  one 
hand,  of  tubercle  bacilli  on  the  other,  may  be  of  much 
assistance  in  the  diagnosis. 

For  the  detection  of  tubercle  bacilli,  the  use  of  a 
centrifugaliser,  or  the  experimental  injection  of  the 
sediment  into  a  guinea-pig,  may  be  desirable. 

The  past  history  or  the  family  history  of  the  case 
may  afford  help  by  pointing  to  the  probability  of 
tubercle  or  of  stone  respectively.  X-rays  may  also 
afford  conclusive  evidence  of  stone  in  the  kidnev, 
ureter,  or  bladder. 

Finally,  direct  examination  of  the  bladder  by  the 
sound  may  reveal  a  stone ;  examination  by  the  cysto- 
scope,  electric  or  other,  may  show  tubercle.  If  the 
kidney  be  the  seat  of  the  disease,  an  exploratory 
operation  alone  may  suffice  for  a  correct  diagnosis. 

With  regard  to  enlargement  of  the  kidney,  it  is  well 

*  A  case  of  this  kind  was  under  my  care  in  the  Eoyal  Free  Hospi- 
tal a  few  years  ago.  A  girl  ^t.  15  had  had  persistent  pyuria  for 
thirteen  years,  but  had  only  very  rarely  had  hfematuria.  A  large 
branched  calculus  was  removed  from  the  pehds  of  the  kidney. 

f  I  have  seen  a  young  woman  die  after  repeated  attacks  of  profuse 
hsematuria,  due  to  tuberculous  disease  of  the  kidneys  and  bladder. 
Pyuria  had  been  a  much  less  prominent  feature  of  the  case. 


2  28  SURGICAL   DIAGNOSIS. 

to  remember  that  stone  in  the  pelvis  of  the  kidney- 
causes  enlargement  of  that  organ  by  blocking  the 
ureter.  A  stone  in  one  of  the  calyces  does  not  block 
the  ureter,  and  consequently  does  not  cause  enlarge- 
ment. A  smooth  stone  firmly  lodged  in  the  upper  end 
of  the  ureter  may  produce  much  enlargement  of  the 
kidney  without  necessarily  producing  either  pyuria  or 
haematuria. 

The  presence  of  a  perinephritic  abscess  is  more  likely 
to  indicate  tubercle  than  calculus,  since  tubercle  is 
more  likely  to  affect  the  substance  of  the  kidney.  Stone 
naturally  affects  the  interior. 

{d)  New  growth. — Painless,  profuse,  and  inter- 
mittent hgematuria  without  other  symptoms  almost 
always  indicates  the  presence  of  a  new  growth  either 
in  the  kidney  or  the  bladder.  Pyuria  is  not  a  pro- 
minent feature,  although  it  may  occur  if  the  growth 
be  ulcerated,  or  if  there  be  accompanying  cystitis. 

In  various  acute  inflammatory  affections  painless 
haematuria  may  occur,  but  is  usually  to  be  distinguished 
from  the  hgematuria  of  new  growth  by  the  presence  of 
other  symptoms,  such  as  albuminuria,  and  by  the  absence 
of  intervals  of  complete  intermission,  which  are  so 
characteristic  of  the  early  stages  of  new  growth. 

If  the  presence  of  a  new  growth  be  complicated  by 
the  existence  of  cystitis  or  other  inflammatory  con- 
dition, the  difficulties  of  diagnosis  are  much  increased. 

The  diagnosis  between  innocent  and  malignant  new 
growths  in  their  early  stages  is  often  very  difficult.  It 
should  be  remembered  that  malignant  growths  of  the 
urinary  tract  are  much  more  common  than  innocent 
ones,  especially  in  persons  of  middle  or  advanced  age. 
In  the  absence  of  definite  evidence  of  innocent  new 


PYURIA   AND   HEMATURIA.  229 

growth,  the  presumption  is  therefore  always  in  iavour 
of  malignancy.  The  positive  evidence  of  innocency  is 
to  be  found  in  the  duration  of  the  haematuria,  and  in 
the  discovery  of  the  actual  tumour,  either  by  the  cysto- 
scope,  or  by  the  examination  of  detached  portions  of 
growth  which  have  been  voided  with  the  urine  or  have 
come  away  after  the  introduction  of  an  instrument, 
such  as  a  catheter  or  lithotrite.  Delicate  villous  pro- 
cesses seen  in  either  of  these  ways  usually  indicate 
innocent  new  growth.  It  must  not,  however,  be  for- 
gotten that  a  growth,  which  at  first  sight  is  apparently 
merely  villous  and  innocent,  sometimes  proves  to  have 
malignant  elements  in  it,  and  is  found  to  run  the 
clinical  course  of  a  malignant  tumour. 

Long  duration  of  the  symptoms  points  unmistak- 
ably to  innocency.  Intermittent  hsematuria  extending 
over  a  period  of  many  years  is  a  common  history  of 
papilloma  of  the  bladder.  On  the  other  hand,  an 
epithelioma  of  the  bladder  may  exist  for  many  months, 
or  even  a  year  or  two,  without  causing  any  marked 
involvement  of  the  general  health. 

Rectal  examination  may  afford  important  evidence  of 
the  existence  of  a  malignant  new  growth  of  the  bladder  ; 
a  hard  mass  felt  at  the  base  of  the  bladder  or  else- 
where generally  points  unmistakably  to  malignancy. 

Innocent  growths,  being  usually  small  and  soft, 
cannot  be  detected  by  rectal  examination.  Intravesical 
examination  by  speculum,  cystoscope,  or  cystotomy 
may  be  necessary  before  an  exact  diagnosis  can  be 
made. 


CHAPTER  XXII. 

DISEASES   OF   THE    SCROTUM  AND  ITS 

CONTENTS. 

In  the  investigation  of  a  scrotal  swelling,  we  have 
first  to  determine  the  structure  or  tissue  in  which  it 
is  situated. 

Thus  it  may  be  a  swelling  of 

(a)  The  skin  or  cellular  tissue, 
(&)  The  tunica  vaginalis, 
(c)  The  testis, 
(cT)  The  spermatic  cord. 

On  the  other  hand,  it  may  be  a  swelling  which  has 
originated  altogether  outside  the  limits  of  the  scrotum, 
and  has  only  come  secondarily  to  occupy  that  part. 
Such  are  hernial  swellings,  and  for  the  diagnosis  of 
swellings  of  this  nature  see  chap.  xvii. 

In  the  examination  of  any  swelling  of  the  scrotum 
or  genital  organs  it  is  well  to  make  a  thorough  inspec- 
tion not  only  of  these  parts  themselves,  but  also  of 
surrounding  parts,  such  as  the  lower  abdomen,  the 
groins,  and  upper  parts  of  the  thighs,  since  disease  may 
there  be  found  which  will  throw  light  upon  the  nature 
of  the  scrotal  swellings. 

After  inspection  of  all  these  parts  it  is  best  to 
examine  systematically  with  the  fingers  and  thumb  the 


DISEASES   OF   THE    SCROTUM.  231 

testis  and  cord  of  each  side,  as  well  as  the  skin  and 
other  tissues. 

The  fingers  should  be  placed  behind  the  scrotum,  the 
thumb  in  front  of  the  upper  portion  of  it,  and  the 
patient  told  to  cough.  In  this  way  it  is  generally  easy 
to  determine  whether  the  swelling  is  limited  to  the 
scrotum  and  its  normal  contents,  or  whether  it  extends 
upwards  out  of  the  scrotum,  e.g.,  along  the  cord,  or 
whether  it  is  a  hernia  or  other  swelling  descending  into 
it  from  above. 

If  it  is  clear  upon  examining  in  this  way  that  the 
fingers  and  thumb  can  be  so  closely  approximated 
above  the  swelling,  that  there  is  nothing  between  them 
but  normal  structures,  such  as  the  spermatic  cord,  then 
it  may  be  concluded  that  the  swelling  belongs  to  one  or 
other  of  the  first  four  above-mentioned  groups. 

If  the  cord  alone  is  felt  to  be  enlarged,  this  may  be 
due  either  to  the  spread  of  inflammation  or  of  new 
growth  along  it  as  in  epididymitis,  or  sarcoma  of  the 
testis,  or  to  mere  hypertrophy  of  the  ere  master  due  to 
the  weight  of  the  swelling  below.  Every  swelling  of 
the  testis  or  tunica  vaginalis,  which  has  existed 
sufficiently  long,  tends  to  cause  some  hypertrophy  of 
the  cord  by  which  it  is  suspended. 

The  condition  of  the  cord  should  be  carefully  com- 
pared with  that  of  the  opposite  side. 

The  condition  of  the  upper  part  of  the  scrotum  and 
the  spermatic  cord  having  been  investigated,  attention 
should  next  be  directed  to  the  testis  itself  and  its 
coverings. 

At  an  early  stage  of  the  examination  it  should  be 
ascertained  whether  both  testes  are  in  their  normal 
situation.     Mistakes  in  diagnosis  frequently  occur  in 


232  SURGICAL   DIAGNOSIS. 

connection  with  misplaced  testes  owing  to  omission  of 
this  simple  observation. 

A  general  swelling  of  the  whole  scrotum  is  very 
rarely  due  to  distension  with  air  or  with  blood.  Dis- 
tension by  air  is  seen  only  in  rare  cases  of  injury  to  the 
thorax  (fractured  ribs  with  wound  of  lung),  in  which 
the  air  extravasated  into  the  cellular  tissue  has  made 
its  way  down  to  the  scrotum.  The  condition  is  easily 
recognised  by  the  extreme  lightness  of  the  scrotal 
swelling,  its  resonance  on  percussion,  and  the  crackling 
sensation  imparted  to  the  examining  finger,  as  well  as 
by  the  history  and  the  existence  of  emphysema  of  the 
cellular  tissue  elsewhere. 

Distension  with  blood  is  seen  only  in  cases  of  inj  ury  ; 
the  condition  is  easily  recognised  by  the  dark  colour  of 
the  swelling  and  by  the  history  of  injury. 

Much  more  common  causes  of  general  swelling  of  the 
scrotum  are  oedema  and  inflammation  acute  and  chronic. 

General  oedema  of  the  scrotum  may  be  merely  a  part 
of  a  general  oedema,  connected  with  disease  of  the 
kidneys  or  heart. 

Acute  inflammation  of  the  cellular  tissue  of  the 
scrotum  may  be  due  to  phlegmonous  inflammation 
(erysipelas)  starting  in  a  wound  of  the  scrotum  or 
spreading  to  it  from  surrounding  parts.  Or  it  may  be 
due  to  the  presence  of  an  abscess  or  to  extravasation  of 
urine.  Erysipelatous  inflammation,  being  above  the 
deep  fascia,  shows  no  tendency  to  be  limited  to  the 
scrotum  and  perineum,  but  spreads  to  the  neighbouring 
regions  of  the  thighs. 

Inflammation  set  up  by  extravasation  of  urine,  or  by 
the  presence  of  an  abscess  of  the  perineum,  is  limited 
sharply  behind  and  on  either  side  by  the  attachments 


DISEASES    OF   THE    SCROTUM.  233 

of  Colles's  fascia,  aad  tends  to  spread  forwards  only, 
into  the  penis  and  scrotum  and  up  on  to  the  front  of 
the  abdomen.  The  examination  of  the  urethra,  prostate 
and  rectum  may  throw  much  light  upon  the  origin 
of  acute  inflammation  of  the  scrotum. 

Chronic  swelling  of  the  whole  scrotum  is  often  seen 
in  connection  with  urinary  fistulas  of  long  standing. 
Eepeated  attacks  of  inflammation  of  the  scrotum  often 
lead  to  a  sort  of  chronic  hypertrophy  that  has  been 
called  spurious  elephantiasis. 

It  is  in  cases  of  true  elephantiasis  that  the  greatest 
amount  of  chronic  swelling  and  thickening  of  the 
scrotum  is  seen.  The  history  of  residence  in  the  tropics, 
the  chronic  nature  of  the  swelling,  the  absence  of  any 
urethral  trouble,  and,  if  necessary,  examination  of  the 
blood  for  filaria,  will  usually  suffice  for  a  correct 
diagnosis. 

In  any  case  of  scrotal  swelling,  whatever  its  cause, 
an  attempt  should  be  made  to  localise  the  testes  and 
cords,  and  to  ascertain  whether  there  is  any  disease  in 
these  organs. 

Localised  swellings  in  the  cellular  tissue  and  un- 
connected with  the  testes  are  rare.  Lipomata  and 
other  innocent  tumours  occasionally  occur  in  this  region, 
but  are  usually  easily  recognised  by  the  ordinary 
character  of  such  tumours. 

Localised  abscesses  of  the  scrotum  are  common,  but 
as  they  are  almost  always  due  to  disease  of  the  testis, 
they  are  directly  connected  with  this  oigan,  and  cannot 
be  separated  from  it. 

A  swelling  limited  to  the  spermatic  cord  is  occasion- 
ally a  tumour,  such  as  a  lipoma.  In  the  vast  majority 
of  cases,  however,  a  swelling  in  this  situation  is  due  to 


2  34  SttRGICAL   DIAGNOSIS. 

local  dilatation  of  the  unobliterated  tunica  vaginalis 
(hydrocele  of  the  cord).  It  presents  itself  as  a  rounded 
smooth  swelling  inseparable  from  the  cord.  A  hydro- 
cele of  the  cord  situated  very  low  down  may  be  so  close 
to  the  testicle  as  to  simulate  a  swelling  of  the  testis 
itself  (encysted  hydrocele  of  the  epididymis).  The 
hydrocele  of  the  cord  can,  however,  almost  always  be 
made  to  move  apart  from  the  testis.  The  hydrocele  of 
the  epididymis  cannot  be  separated  from  the  testis. 
Translucency  is  usually  obtainable  in  both  varieties  of 
encysted  hydrocele  and  reveals  the  cystic  nature  of  the 
tumour.  A  simple  tapping  will  reveal  the  presence 
of  a  straw-coloured  fluid  if  the  hydrocele  be  of  the 
cord,  that  is,  derived  from  the  peritoneal  process. 

A  hydrocele  of  the  epididymis,  on  the  other  hand, 
contains  a  watery  fluid  of  low  specific  gravity,  often 
with  a  milky  tinge  due  to  the  presence  of  spermatozoa 
in  it. 

Swellings  of  the  tunica  vaginalis  are  due  to  distension 
with  serous  fluid  or  with  blood  (vaginal  hydrocele  or 
hgematocele). 

In  both  cases  the  swelling  surrounds  the  testis,  which 
is  felt  indistinctly  at  the  back  and  lower  part  of  the 
swelling,  or  is  not  felt  at  all.  Translucency  is  usually 
enough  for  the  diagnosis  of  a  hydrocele.  If  the  wall  is, 
however,  very  thick,  this  sign  may  not  be  available. 
But  in  this  case,  the  very  long  duration  of  the  swelling 
will  suggest  a  hydrocele.  Or  a  tapping  will  reveal  the 
presence  of  clear  fluid.  In  infants  a  hernia  may  be 
translucent  to  a  certain  extent. 

Haematocele  is  generally  more  rounded  than  the 
hydrocele,  which  is  usually  oval  or  pyriform.  It  is  often 
distinctly   heavier   than   the    hydrocele.     It    is   never 


DISEASES    OF   THE    SCROTUM.  ^35 

translucent.  The  overlying  skin  and  cellular  tissue  may 
be  discoloured,  especially  if  the  hssmatocele  is  recent ;  a 
history  of  injury  is  usually  obtainable.  Tapping  may 
be  necessary  before  the  diagnosis  is  clearly  established. 

It  should  be  remembered  that  both  hydrocele  and 
hsematocele  may  be  merely  secondary  to  disease  of  the 
testis  itself;  the  condition  of  the  latter  organ  should 
always  be  ascertained  if  possible. 

A  favourable  opportunity  for  examination  of  the 
testis  is  presented  immediately  after  the  withdrawal  of 
fluid  by  tapping.  Both  hydrocele  and  hsematocele  may 
be  very  closely  simulated  by  soft  elastic  swellings  of  the 
testis  itself  {e.g.,  soft  sarcoma),  especially  if  the  tests  of 
translucency  and  tapping  have  not  been  applied. 

Swellings  of  the  testis  itself  have,  however,  but 
seldom  the  uniform  smoothness  of  a  swelling  which  is 
due  to  the  accumulation  of  fluid  within  the  tunica 
vaginalis. 

In  the  examination  of  a  swelling  of  the  testis  itself 
an  attempt  should  always  be  made  to  feel  the  epi- 
didymis. Swellings  involving  mainly  the  epididymis 
are  usually  either  inflammatory,  due  to  the  spread  of 
inflammation  along  the  vas  deferens  (as  in  gonorrhoea! 
epididymitis),  or  they  are  due  to  the  local  deposition  of 
tubercle.  In  either  case  the  vas  deferens  will  probably 
be  found  to  be  thick  and  hard. 

A  swelling  which  involves  the  body  of  the  testis  and 
not  the  epididymis  is  probably  either  syphilitic  or 
a  malignant  new  growth.  In  the  diagnosis  between 
tuberculous  and  syphilitic  diseases  of  tbe  testis,  the 
history  and  the  existence  of  lesions  in  other  parts  of 
the  body  may  throw  much  light  on  the  nature  of  the 
affection. 


236  SURGICAL   DIAGNOSIS. 

Tuberculous  disease  of  the  testis  is  especially  apt 
to  be  accompanied  b}'"  disease  of  other  parts  of  the 
urinary  organs  ;  examination  of  the  vesiculae  seminales 
per  rectum,  of  the  kidneys  by  palpation,  and  of  the  urine, 
are  therefore  important  factors  in  the  diagnosis. 

A  tendency  to  the  formation  of  abscess  in  or  close  to 
the  testicle  points  to  tubercle. 

A  very  hard  painless  testicle  is  probably  syphilitic. 
The  presence  of  hydrocele   with  a  solid  enlargement 
of  the  testis  generally  points  to  syphilis,  but  is  also  not 
very  uncommon  in  connection  with  tubercle. 

The  presence  of  haematocele  with  a  solid  enlargement 
of  the  testis  is  suggestive  of  malignant  disease,  especially 
if  no  history  of  injury  is  obtainable. 

Solid  tumours  of  the  testis  originate  almost  invariably 
in  the  body  of  that  organ.     Innocent  tumours  are  very 
rare,  and  are  to  be  diagnosed  chiefly  by  the  very  slow 
but  steady  growth  ;  enchondroma  is,  perhaps,  the  least 
uncommon,  and  is  characterised  by  its   extreme  hard- 
ness.    Malignant  disease  is  on  the  other  hand   only  too 
common,   and  is  frequently  very  difficult  to  diagnose. 
Steady  and  rapid  increase  in  size  of  a  swelling  origi- 
nating in  the  body  of  the  testis  is  extremely  suggestive 
of  new   growth,  in  the  absence  of  anything  pointing 
directly  to  inflammation.     In  the  earliest  stage,  before 
the  tunica  albuginea  has  been  perforated,  there  may  be 
a  certain  amount  of  pain,  which  lessens  when  the  growth 
is  more  free  to  expand.     As  soon   as  the  growth  has 
extended  beyond  the  tunica  albuginea,  the  growth  tends 
to  become  irregular.     A  painless  swelling  that  is   soft 
and  elastic  in  some  parts  and  harder  in  others  is  likely 
to   be   a  malignant  new  growth.     A  soft  elastic  new 
growth  of  moderate  size  is  likely  to  be  mistaken  on  the 


DISEASES    OF    THE    SCROTUM.  237 

one  hand  for  a  fluid  swelling  (hydrocele  or  heematocele), 
from  which  it  is  most  readily  distinguished  by  the 
absence  of  translucency  or  by  the  result  of  tapping. 
A  hgematocele  yields  dark  altered  blood,  a  malignant 
tumour  nothing  at  all  or  at  most  a  few  drops  of  fresh 
blood.  Malignant  disease  is,  on  the  other  hand,  often 
closely  simulated  by  chronic  or  subacute  inflammatory 
affections,  such  as  syphilitic  disease  or  tubercle  affecting 
the  body  of  the  testis. 

It  is  important  to  remember  that  the  lymphatics  from 
the  testis  pass  to  the  lumbar  glands  and  not  to  the  in- 
guinal, which  receive  those  of  the  scrotum.  Affections 
of  the  testis  therefore  tend  to  cause  enlargement  of 
lumbar  glands,  while  those  of  the  superficial  parts  tend 
to  involve  the  inguinal  glands. 

In  conclusion,  the  reader  may  be  reminded  that  the 
coexistence  of  two  or  more  diseases  in  the  scrotum  is 
very  common.  Thus,  hernia  may  occur  with  hydrocele, 
or  either  of  these  with  varicocele,  and  so  on. 

The  diagnosis  of  a  single  diseased  condition  does  not 
by  any  means  necessarily  complete  the  diagnosis  of  the 
whole  case. 


CHAPTER  XXIII. 

DISEASES  OF  BONE. 

Congenital  malformations  of  boue  present  little 
or  no  difficulty  in  diagnosis.  A  bone  may  be  con- 
genitally  small  or  rudimentary  as  in  the  case  of 
so-called  intra-uterine  amputations,  where  one  or  more 
of  the  bones  of  a  limb  is  represented  by  a  mere 
irregular  fragment  of  bone. 

It  may  be  congenitally  malformed — e.g.,  the  vertebrae 
in  a  case  of  spina  bifida,  the  pelvis  and  femur  in  a  case 
of  congenital  dislocation  of  the  hip. 

It  may  be  congenitally  enlarged,  as  in  the  case  of  the 
phalanges  in  macrodactyly. 

Atrophy  of  bone  likewise  presents  but  little  diffi- 
culty in  diagnosis.  The  bone  is  more  slender  than 
normal,  as  in  the  bones  of  a  limb  in  which  chronic  joint 
disease  has  existed  for  a  long  time.  Disuse  of  the 
bone  is  the  main  cause  of  atrophy.  A  limb  that  has 
long  been  the  seat  of  infantile  paralysis  shows  atrophy 
of  all  its  bones.  The  bones  of  a  bed-ridden  patient 
generally  show  atrophy  for  the  same  reason. 

Local  atrophy  or  absorption  from  pressure  may  be 
produced  by  anything  that  presses  continuously  for  a 
long  time  upon  the  part.  An  innocent  tumour  lying 
in  close  contact  with  a  bone  may  lead  to  a  hollow  in 


DISEASES    OF    BONE.  239 

the  neighbouring  portion  of  the  bone.  A  slowly- 
growing  fibrous  tumour  of  the  naso-pharynx  may  cause 
much  atrophy  of  the  superior  maxilla.  The  atrophy  of 
the  bodies  of  the  vertebras  from  the  pressure  of  an 
aneurism  is  a  familiar  instance. 

The  atrophy  produced  by  the  pressure  of  an  innocent 
tumour  must  be  distinguished  from  the  destruction  of  a 
bone  by  the  invasion  of  a  new  growth.  A  sarcoma  of 
the  femur  eats  into  and  destroys  the  bone,  but  this  is 
not  atrophy. 

Softening  of  bones  is  produced  by  certain  general 
diseases,  of  which  the  most  familiar  is  rickets.  A 
much  less  common  and  little  understood  disease 
attended  by  marked  softening  of  adult  bones,  is  osteo- 
malacia (mollities  ossium). 

A  softened  bone  naturally  tends  to  yield  and  to 
become  bent.  Hence  the  bent  bones  so  characteristic 
of  rickets. 

Unnatural  hardening  of  bone  is  almost  always 
produced  by  chronic  inflammation  (sclerosis).  Un- 
natural brittleness  of  bone  is  sometimes  produced, 
however,  by  certain  nervous  diseases  as  locomotor 
ataxy,  and  perhaps  by  chronic  rheumatoid  arthritis. 
The  frequent  occurrence  of  fracture  of  the  patella  in 
the  same  patient  on  one  or  both  sides  of  the  body,  can 
sometimes  be  explained  only  on  the  supposition  that 
the  bones  are  preternaturally  brittle. 

General  enlargement  of  a  bone  may  be  due  to 
mere  hypertrophy,  compensatory  in  nature.  Thus  con- 
genital absence  of  the  tibia  causes  hypertrophy  of  the 
remaining  fibula,  owing  to  the  increased  strain  thrown 
upon  that  bone. 

pertain   general   diseases    such    as   acromegaly  are 


240  SURGICAL    DIAGNOSIS. 

attended  by  great  enlargement  of  some  of  the  bones ; 
the  cause  of  this  enlargement  is  ill  understood. 

Osteitis  deformans  is  another  disease  characterised  by 
the  slow  and  painless  enlargement  of  certain  bones, 
notably  the  tibia  and  the  skull.  All  the  bones  of  the 
skeleton  tend,  in  time,  to  become  affected.  The  disease, 
although  possibly  inflammatory  in  nature,  differs  from 
most  inflammatory  affections  of  bone  in  being  wholly 
unattended  by  pain  or  by  any  of  the  other  symptoms 
that  usually  accompany  inflammation  of  bone. 

Deformity  of  a  bone,  especially  of  a  long  bone,  is 
caused  by  fracture,  by  bending,  by  various  forms  of 
inflammatory  swelling,  and  by  the  growth  of  tumours 
within  the  bone  or  springing  from  it. 

Local  S'welling  of  a  bone  is  due  in  the  vast 
majority  of  cases,  either  to  some  form  of  inflammation 
or  to  the  presence  of  a  tumour. 

Inflammatory  affections  of  bone. — The  diag- 
nosis of  an  inflammatory  affection  of  a  bone  is  to  be 
made  partly  by  the  general  symptoms  of  septic  absorp- 
tion, partly  by  the  presence  of  signs  and  symp- 
toms elsewhere  of  some  general  disease  such  as 
syphilis,  tubercle  or  rheumatism,  and  partly  by  the 
local  signs. 

The  general  symptoms  of  septic  absorption  vary 
according  to  the  acuteness  and  infectivity  of  the  local 
inflammation. 

Thus  in  the  most  acute  form  of  osteitis,  the  infective 
osteitis  (acute  infective  periostitis,  acute  necrosis), 
general  symptoms  of  blood-poisoning  set  in  early. 
They  are  mainly  high  temperature,  rigors,  flushed  face, 
quick  pulse,  and  then  pleurisy,  pericarditis,  or  some 
other  evidence  of  a  general  visceral  septic  infection. 


DISEASES   OF   BONE.  24 1 

The  local  signs  are  those  of  iuiiainmation  more  or  less 
marked  as  the  bone  is  or  is  not  superficially  situated. 

Thus  acute  osteitis  of  the  tibia  is  attended  by  pain, 
tenderness,  and  swelling  of  the  neighbouring  soft  parts. 
Kedness  and  oedema  of  the  skin  is  generally  an  early 
sign  of  acute  osteitis  of  a  superficial  bone,  such  as  the 
tibia  or  clavicle.  If  a  deep-seated  bone  such  as  the 
humerus  or  femur  be  the  seat  of  disease,  the  skin  may 
be  unafiected  for  a  long  time.  The  deep-seated  swelling 
around  the  bone  causes,  however,  a  general  thickening  of 
the  limb  and  tension  of  the  skin.  In  some  cases  the  deep 
swelling  of  the  limb  causes  an  actual  blanching  of  the 
skin,  which  is  tightly  stretched  over  the  deeper  parts. 

Local  and  deep  tenderness,  which  may  be  very  acute, 
is  the  most  valuable  sign  of  acute  osteitis. 

Acute  osteitis  or  periostitis  of  a  long  bone  is  most 
likely  to  be  mistaken  for  an  inflammation  of  the  soft 
parts  over  the  bone.  The  deep-seated  tenderness  and 
the  fact  that  the  inflammatory  area  corresponds  exactly 
to  the  situation  of  the  bone  will  generally  serve  to  dis- 
tinguish the  affection  of  the  bone  from  other  more 
superficial  inflammations. 

An  erysipelatous  or  other  acute  cellulitis  of  the  leg 
may  at  first  resemble  an  acute  osteitis  of  the  tibia.  The 
erysipelatous  inflammation  is,  however,  not  limited  to 
the  area  of  the  tibia,  whereas  the  inflammatory  swelling 
due  to  disease  of  the  bone  is  in  the  main  so  limited,  and 
is  most  marked  over  the  part  where  the  bone  is  nearest 
to  the  surface. 

Scurvy  rickets,  with  its  attendant  effusion  of  blood 
beneath  the  periosteum,  is  extremely  likely  to  be  con- 
fused with  acute  periostitis,  especially  as  both  are  prone 
to  occur  in  children.     Scurvy  rickets  is,  however,  more 

Q 


242  SURGICAL   DIAGNOSIS. 

likely  to  occur  in  very  young  children  at  an  age  when 
acute  periostitis  is  less  common.  The  multiple  lesions 
of  the  former  disease,  together  with  the  general  symp- 
toms of  the  disease  and  probably  the  absence  of  the 
very  acute  local  symptoms,  will  generally  help  in  the 
diagnosis. 

Acute  periostitis  affecting  an  epiphysis  often  closely 
resembles  an  acute  inflammation  of  the  neighbouring 
joint.  It  can  generally  be  distinguished  by  careful 
observation  of  the  exact  seat  of  the  swelling,  which  is 
close  to  the  joint  rather  than  at  the  joint.  There  is  also 
less  likelihood  of  the  movements  of  the  joint  being 
seriously  interfered  with.  It  must  not  be  forgotten, 
however,  that  an  affection  primarily  of  the  epiphysis  may 
also  involve  the  articulation.  Sometimes  careful  atten- 
tion to  the  history  will  indicate  the  exact  date  at  which 
the  epiphysial  inflammation  extended  to  the  joint. 

The  diagnosis  of  the  more  chronic  inflammatory  affec- 
tions of  bone  generally  resolves  itself  into  the  diagnosis 
of  a  local  inflammation  of  bone,  and  the  diagnosis  of  the 
cause,  such  as  tubercle,  syphilis,  or  injury;  the  two  former 
showing  probably  evidence  elsewhere  of  tb  eir  existence, 
the  latter  by  the  history  or  by  marks  of  injury. 

Abscess  of  bone  may  be  diagnosed,  or  at  least  strongly 
suspected,  by  dull  localised  pain  at  the  end  of  a  long 
bone,  with  some  local  thickening  and  local  tenderness. 
There  may  or  may  not  be  elevation  of  temperature. 
The  existence  of  oedema  over  the  affected  part  is  cor- 
roborative of  abscess  in  the  bone  beneath. 

The  diagnosis  between  tumours  (new 
growths)  and  inflammatory  affections  of  bone 
is  often  exceedingly  difficult.  The  difiiculty  is  in- 
creased if  the  tumour  happen  to  be  also  inflamed. 


DISEASES    OF   BONE.  243 

The  history  of  a  new  growth  is  that  of  a  steadily 
increasing  swelling ;  a  slow  increase  in  size  if  the 
tumour  be  innocent,  more  rapid  if  it  be  malignant. 
Tumours  in  their  early  stages  rarely  cause  any  symptoms 
except  those  which  may  be  caused  by  the  mechanical 
effects  of  pressure. 

Inflammatory  swellings  are  generally  accompanied  by 
some  general  symptom  of  the  disease  which  is  the  cause, 
or  by  some  point  in  the  history  which  will  indicate  in- 
flammation. On  the  other  hand,  a  malignant  tumour 
may  be  attributed  to  a  local  injury.  In  their  early 
stages,  tumours  which  develop  within  a  bone  may  cause 
considerable  dull  aching  pain.  It  is  also  well  known 
that  a  malignant  tumour  growing  under  conditions  of 
tension  may  cause  a  distinct  elevation  of  temperature. 

With  regard  to  local  signs,  it  may  be  stated  that  as  a 
general  rule  a  tumour  stands  out  prominently  from  the 
bone,  and  does  not  involve  any  great  length.  It  has 
usually  a  tolerably  well-defined  or  even  abrupt  margin, 
whereas  inflammatory  swellings  more  often  shelve  off 
into  the  surrounding  bone.  An  actually  overhanging 
edge  is  exceedingly  characteristic  of  an  innocent  bony 
tumour,  the  common  exostosis  of  the  femur,  for  example. 

A  swelling  which  arises  abruptly  from  an  otherwise 
healthy  bone  is  not  at  all  likely  to  be  of  an  inflammatory 
nature.  Tumours  which  originate  within  the  bone  and 
expand  it  have  not  the  same  abrupt  margin.  A  myeloid 
sarcoma,  for  instance,  has  not  the  same  well-defined 
edge  that  the  periosteal  sarcoma  presents.  A  tumour 
covered  with  a  thin  shell  of  bone,  such  as  a  myeloid 
sarcoma,  often  presents  a  very  characteristic  sign,  that 
of  "egg-shell  crackling"  of  the  thin  bony  layer  that 
covers  it. 


244  SURGICAL   DIAGNOSIS. 

The  difficulty  of  diagnosis  between  inflammatory 
affections  and  malignant  tumours  is  greatly  increased 
when  the  swelling  affects  a  deeply-seated  bone,  such 
as  the  femur  or  the  ilium.  The  muscles  and  other  soft 
parts  cover  up  the  swelling,  and  render  exact  palpation 
difficult.  Sarcomata  affecting  the  shaft  of  a  long 
bone,  such  as  the  femur,  may  thus  appear  to  have  a 
fusiform  shape  and  simulate  inflammatory  swellings. 

Occasionally  a  considerable  mass  of  inflammatory 
bone  may  surround  a  small  sequestrum,  and,  in  the 
absence  of  reliable  history,  may  easily  simulate  a 
sarcoma. 

In  some  cases  the  diagnosis  is  impossible  until  after 
an  incision  has  been  made  into  the  tumour.  Even  then 
it  has  sometimes  been  found  that  inflamed  soft  tissues 
have  resembled  sarcomatous  tumours  so  closely  that 
amputation  has  actually  been  performed  in  the  belief 
that  it  was  being  done  for  a  malignant  tumour.  The 
inflammatory  tumour  that  is  most  likely  to  be  mistaken 
for  a  sarcoma  is  that  which  surrounds  a  small  piece  of 
necrosed  bone.  Necrosis  may  occur  very  quietly  and 
without  external  suppuration,  and  the  absence  of  any 
acute  symptoms  may  thus  give  rise  to  the  diagnosis  of 
tumour. 

The  use  of  the  Eontgen  rays  may  help  in  the  diagnosis 
between  a  tumour  and  an  inflammatory  affection.  It 
is.  however,  not  a  very  reliable  means  of  diagnosis.  In 
a  well-marked  case  of  tumour,  however,  in  which  a  con- 
siderable portion  of  bone  has  been  eaten  away  by  the 
growth,  the  skiagram  may  be  very  characteristic. 

'*  Spontaneous  "  fracture — that  is,  fracture  from 
a  very  slight  degree  of  violence — always  indicates  weak- 
ness of  the  bone  at  the  seat  of  fracture.    Nearly  always 


DISEASES    OF   BONE.  245 

it  means  the  presence  of  a  malignant  new  growth  in  the 
bone,  either  a  primary  sarcoma  or  a  secondary  carcinoma. 
Its  occurrence  should  always  raise  a  strong  suspicion  of 
new  growth,  and  should  lead  to  a  careful  examination 
to  see  whether  any  evidence  of  a  local  tumour  can  be 
detected,  or  of  a  primary  carcinomatous  tumour  else- 
where. 

Spontaneous  fracture  does  not  necessarily  indicate 
new  growth.  It  is  sometimes  due  to  tuberculous  disease 
(caries  or  necrosis)  which  has  weakened  the  bone.  Ter- 
tiary syphilitic  disease  sometimes  produces  the  same 
effect.  Necrosis  not  due  to  tubercle  does  not  as  a  rule 
lead  to  fracture,  because  of  the  compensating  new  bone 
that  is  thrown  out  around  the  necrosed  portion. 
"Spontaneous"  fracture  is  occasionally^  due  to  mere 
brittleness  of  the  bone,  as  in  some  cases  of  locomotor 
ataxy,  and  in  the  atrophied  bones  of  elderly  subjects. 


CHAPTEE  XXIV. 

DISEASES  OF  JOINTS. 

The  physical  examination  of  a  joint  should  be  made,  as 
far  as  possible,  wlien  tlie  latter  is  in  a  state  of  rest.  If 
the  neighbouring  muscles  and  tendons  are  thoroughly- 
relaxed,  the  examination  of  the  underlying  joint  is 
facilitated.  Thus  a  knee  should  be  examined  when 
the  leg  is  lying  in  the  extended  position,  with  the  foot 
or  the  whole  limb  supported  by  the  bed,  couch,  or 
chair. 

The  examination  should  not  be  confined  simply  to 
the  most  accessible  part  of  a  joint,  but  should  include 
all  its  aspects.  Thus,  much  can  often  be  learnt  about  a 
knee-joint  by  examination  of  its  posterior  aspect,  by 
passing  the  fingers  deeply  into  the  popliteal  space,  the 
muscles  being  at  the  same  time  relaxed  by  flexing  the 
knee.  Similarly,  disease  of  the  shonlder-joint  may 
often  be  investigated  with  advantage  by  passing  the 
fingers  up  into  the  axilla.  In  this  situation  the  joint  is 
more  accessible  to  direct  examination  than  it  is  on  its 
outer  or  superficial  aspect,  where  it  is  covered  by  the 
thick  deltoid  muscle. 

In  investigating  the  condition  of  a  joint  we  have  to 
consider  the  following  points,  which  may  be  discussed 
seriatim : 


DISEASES    OF   JOINTS.  247 

I.  Pain. 

II.  Presence  of  swelling  in  or  near  the  joint. 

III.  The  relative  position  of  the  bones  that  enter 

into  its  formation. 

IV.  The  condition  of  the  muscles   surrounding  it, 

especially  as  regards  wasting  and  spasm. 

V.  The  movements. 

I.  Pain  felt  in  a  joint  may  be  due  to  disease  of  the 
joint  itself  or  to  disease  of  the  bones  or  soft  parts  in 
close  proximity  to  the  joint ;  or  it  may  be  due  to  disease 
of  some  other  part,  the  pain  being  merely  referred  to 
the  joint. 

Pain  of  the  last  kind  is  usually  easily  detected  by 
the  complete  absence  of  any  local  sign  of  disease  in  the 
joint  in  which  the  pain  is  felt,  together  with  the 
presence  of  signs  of  disease  in  some  other  part  which 
is  really  the  seat  of  disease. 

The  pain  in  the  knee,  which  is  such  a  familiar 
symptom  of  hip-disease,  affords  a  good  illustration ;  so 
does  the  pain  in  the  hip,  which  is  a  common  symptom 
of  disease  of  the  lumbar  or  sacral  spine. 

Pain  due  to  disease  of  bone  or  soft  parts  in  close 
proximity  to  the  joint,  is  generally  diagnosed  without 
much  difficulty  by  the  presence  of  local  swelling  or 
tenderness  at  the  seat  of  disease. 

A  constant  dull  pain,  not  increased  by  movement  of 
the  joint,  generally  indicates  disease  of  the  unyielding 
bone  rather  than  of  the  softer  structures  of  the  joint. 

The  pain  that  is  most  characteristic  of  disease  of  a 
joint,  and  especially  of  ulceration  of  the  articular  end 
of  one  of  the  constituent  bones,  is  the  so-called  starting 
pain.  This  symptom,  when  present,  is  a  valuable  in- 
dication  of  active   inflammatory   disease.      It  occurs 


248  SURGICAL    DIAGNOSIS. 

suddenly,  just  as  tlie  patient  is  dropping  off  to  sleep, 
and  is  due  to  the  relaxation  and  then  spasm  of  the 
surrounding  muscles.  The  relaxation  of  the  muscles 
allows  the  bones  to  separate  slightly,  the  subsequent 
S23asm  brings  the  inflamed  surfaces  violently  into 
contact,  and  causes  the  attack  of  sharp  pain.  This 
symptom  is  sometimes  said  to  indicate  ulceration  of 
articular  cartilage.  It  betokens  rather  that  the  bone 
beneath  the  cartilage  has  been  exposed  by  the  destruc- 
tion of  the  cartilage  over  it.  It  is  the  inflamed  bone 
that  is  tender,  not  the  ulcerated  cartilage. 
11.  Presence  of  s"welling. 

(a)  Within  the  joint — (i)  Effusion  of  fluid. 

(a)  Synovia. 
(/3)  Blood. 
(y)  Pus. 
(ii)  Solid — loose  cartilage. 

(b)  Of  the  synovial  membrane. 

(c)  In  the  neighbourhood  of  the  joint. 

(i)  In  the  articular  ends  of  the  bones, 
(ii)  In  the  soft  parts  outside  the  joint, 
(a)  Swelling  within  the  Joint. 

(i)  Effusion  of  Fluid. — (a)  Synovia. 
An  effusion  of  fluid  into  a  joint,  if  sufficiently  great, 
causes  an  enlargement  which  may  be  obvious  to  sight 
and  touch,  if  the  joint  be  large  and  superficial,  such  as 
the  knee-joint.  If  the  joint  be  deeply  seated,  such  as 
the  hip,  the  swelling  is  naturally  less  easily  detected, 
unless  the  amount  of  fluid  be  considerable. 

It  is  in  cases  of  chronic  eff*usion,  in  which  the 
synovial  membrane  has  become  distended  by  the  intra- 
articular pressure,  that  the  swelling  attains  its  greatest 
size. 


DISEASES    OF   JOINTS.  249 

An  effusion  into  a  joint  causes  a  swelling  which 
preserves  the  natural  shape  of  the  synovial  cavity. 
This  shape  may  be  exceedingly  characteristic.  The 
horseshoe-shaped  swelling  of  the  knee-joint,  most 
marked  above  and  on  either  side  of  the  patella,  is  the 
best  example  that  can  be  adduced.  The  swelling  of  an 
eflfusion  into  the  ankle,  at  the  front  and  back  of  the 
joint,  and  around  each  malleolus,  less  prominent  where 
it  is  bound  down  by  more  or  less  rigid  structures  such 
as  the  tendo  Achillis  behind  and  the  extensor  tendons 
in  front,  is  also  a  good  example. 

There  are,  however,  two  exceptions  to  the  rule  that 
an  effusion  causes  a  uniform  distension  of  a  joint. 
One  is  the  rare  case  in  which  the  fluid  accumulates  in 
a  part  only  of  the  joint,  the  rest  of  the  cavity  having 
been  shut  off  by  adhesions  or  obliterated  by  previous 
disease.  The  other  is  the  also  somewhat  rare  case  in 
which  a  local  yielding  of  the  synovial  membrane 
occurs,  allowing  the  fluid  to  protrude  at  one  or  more 
places  in  the  form  of  a  rounded  or  even  pear-shaped 
swelling. 

Such  local  protrusions  are  most  common  in  connec- 
tion with  the  knee,  and  may  extend  for  several  inches 
down  the  leg  among  the  muscles  of  the  calf  (Morrant 
Baker's  cysts).  Occasionally  the  narrow  communica- 
tion between  the  cyst  and  the  joint  becomes  completely 
closed,  so  that  the  protrusion  exists  as  an  independent 
cyst.  The  diagnosis  may  generally  be  made  without 
difficulty  if  the  communication  still  exists,  by  pressing 
the  fluid  back  into  the  joint.  If  the  cyst  is  indepen- 
dent of  the  joint,  the  diagnosis  is  more  difficult ;  but 
the  situation  near  a  joint,  and  probably,  some  evidence 
of   fluid   or   other    disease    in    the    joint    itself,    will 


250  SURGICAL   DIAGNOSIS. 

generally  suffice  for  a  diagnosis.  Tapping  of  the  cyst, 
and  the  evacuation  of  straw-coloured  oily  fluid  resem- 
bling synovia,  may  be  necessary  before  the  diagnosis 
can  be  established  with  certainty. 

A  hip- joint  occasionally  presents  a  large  rounded 
prominent  swelling  of  this  nature  on  its  anterior 
aspect,  lifting  up  or  displacing  to  one  side  the  femoral 
artery. 

These  local  dilatations  of  a  joint  are  most  often 
associated  with  chronic  rheumatoid  arthritis. 

A  simple  effusion  into  a  joint  is  caused  either  by 
some  purely  local  change,  such  as  inflammation  of  the 
synovial  membrane,  injury,  &c.  ;  or  it  may  be  due  to 
some  general  blood-poisoning,  using  this  term  in  its 
widest  sense.  The  synovial  cavity  of  a  joint  commu- 
nicates freely  with  the  lymphatic  vessels,  and  is  to  be 
regarded  as  a  dilated  portion  of  the  lymphatic  system, 
similar  in  this  respect  to  the  pleura,  peritoneum,  and 
other  large  serous  cavities  of  the  body.  It  is  easy 
therefore  to  understand  why  a  general  infection,  such 
as  pysemia,  or  acute  rheumatism,  displays  a  tendency 
to  cause  inflammation  of,  and  effusion  into,  joints. 
More  chronic  forms  of  blood-poisoning,  such  as 
gonorrhoeal  rheumatism,  syphilis,  and  tuberculosis, 
show  a  similar  tendency  to  infect  joints,  but  in  a 
less  severe  degree. 

(j3)  Blood  within  a  joint  almost  always  indicates  a 
recent  injury.  It  is  often  a  sign  of  a  fracture  of  a 
neighbouring  bone,  the  line  of  fracture  running 
through  the  cartilage  into  the  joint.  Thus  fractures  of 
the  lower  end  of  the  humerus  or  the  ujDper  end  of  the 
tibia  are  often  accompanied  by  an  effusion  of  blood  or 
blood-stained  fluid  into  the  elbow  or  knee. 


DISEASES    OF    JOINTS.  25 1 

A  spontaneous  effusion  of  blood  into  a  joint  rarely 
occurs  excepb  in  hgemopliilia,  the  diagnosis  of  which  is 
made  chiefly  by  the  previous  history  and  by  the  family 
history.  Blood  within  a  joint  generally  causes  after  a 
short  time  some  dusky  discoloration  of  surrounding 
parts,  especially  if  the  joint  be  large  and  superficial,  as 
the  knee.  Very  rarely  the  presence  of  blood  within  a 
joint  is  due  to  the  penetration  of  the  joint  by  some 
malignant  growth.  This  sign  of  a  malignant'  growth 
is,  however,  never  seen  except  in  late  stages,  when 
the  diagnosis  is  no  longer  a  matter  of  doubt. 

Considerable  distension  of  a  joint  coming  on  very 
rapidly,  say  within  an  hour,  generally  indicates  an 
effusion  of  blood.  Distension  occurring  more  slowly 
usually  indicates  an  inflammatory  effusion. 

(y)  The  diagnosis  of  pus  within  a  joint  is  generally 
made  partly  by  the  constitutional  signs,  such  as 
elevation  of  temperature  denoting  septic  absorption, 
and  partly  by  the  severity  of  the  local  signs,  such  as 
tenderness.  If  the  inflammation  have  made  its  way 
through  the  synovial  membrane  into  surrounding 
tissues,  then  oedema,  redness,  or  other  signs  of  local 
suppuration  may  afford  valuable  indications  of  the 
probable  presence  of  pus  within  the  joint.  It  must 
not  be  forgotten,  however,  that  pus,  especially  in 
cases  of  tuberculous  disease,  may  exist,  even  in  con- 
siderable quantity,  within  a  joint,  and  yet  give  rise 
to  little  or  no  constitutional  disturbance,  and  to  but  few 
local  signs.  In  such  cases  the  diagnosis  between  serous 
and  purulent  effusion  may  be  possible  only  after  the 
aspirator  has  revealed  the  exact  nature  of  the  fluid. 

The  presence  of  pus  within  a  deeply-seated  joint, 
such  as  the  hip,  frequently  gives  no  definite  sign  of 


252  SURGICAL   DIAGNOSIS. 

its  presence  until  the  fluid  has  made  its  way  through 
the  capsule  and  formed  a  definite  swelling  in  the 
neighbourhood  of  the  joint.  Occasionally  such  local 
collections  of  pus  form  outside  a  diseased  joint 
without  any  direct  communication  with  its  interior. 
They  may  originate  in  the  substance  of  the  thickened 
synovial  membrane  or  outside  it.  But  more  often 
such  collections  will  be  found  to  have  a  direct  com- 
munication with  the  interior  of  the  joint  itself. 

(ii)  Solid. — The  loose  cartilage,  the  only  solid 
substance  found  within  a  joint,  is  usually  easily 
diagnosed  by  the  history  and  by  the  physical  signs, 
lioose  cartilages  are  found  almost  exclusively  in  the 
knee-joint,  but  occasionally  occur  in  the  elbow  and 
even  in  other  joints.  So  long  as  the  cartilage  does 
not  get  caught  between  the  ends  of  the  bones,  it 
causes  no  symptoms.  But  when  this  accident  does 
occur,  a  sharp,  sudden,  sickening,  and  severe  pain  is 
produced,  and  the  joint  may  become  locked.  An 
effusion  into  the  joint  usually  follows,  and  may  last 
for  a  few  days  or  even  weeks.  This  effusion  may 
hide  the  cartilage  and  render  its  palpation  difficult. 
A  history  of  this  kind  should,  however,  lead  to  a 
strong  suspicion  of  loose  cartilage,  even  if  the  carti- 
lage itself  cannot  be  felt.  But  usually,  careful  exam- 
ination of  the  joint  reveals  the  presence  of  one  or  more 
loose  bodies  slipping  about  inside  the  joint. 

Sometimes  the  cartilage  is  more  or  less  fixed  by  a 
stalk  to  the  synovial  membrane.  The  presence  of 
rheumatoid  arthritis  also  helps  towards  a  diagnosis. 

The  dislocated  semilunar  cartilage  presents  symptoms 
somewhat  similar  to  that  of  the  true  loose  cartilage. 
There  is,  however,  in  these  cases  always  a  history  of 


DISEASES    OF   JOINTS.  253 

injury ;  the  joint  is  more  likely  to  be  locked  when  the 
cartilage  becomes  displaced,  and  the  displacement  can 
often  be  felt  by  direct  examination.  A  transverse  de- 
pression or  elevation  at  the  side  of  the  joint,  usually  the 
inner  side,  and  just  where  the  femur  and  tibia  meet, 
show  that  the  semilunar  cartilage  has  become  displaced. 
(b)  Swelling  of  synovial  membrane. 
Chronic  inflammation  of  a  joint,  and  especially  tuber- 
culous inflammation,  leads  to  general  thickening  and 
swelling  of  the  synovial  membrane.  If  the  joint  be 
deeply  seated,  as  the  hip,  it  may  be  impossible  to  feel 
this  or  to  feel  more  than,  at  most,  an  indistinct  fulness 
in  the  region  of  the  joint. 

If,  however,  the  joint  be  large  and  superficial,  then 
the  thickened  synovial  membrane  can  easily  be  felt  and 
recognised.  The  shape  of  the  joint  whose  synovial 
membrane  is  swollen  is  exactly  the  same  as  that  which 
is  distended  with  fluid.  The  former  has,  however,  a 
more  doughy  feeling,  and  the  latter  may  give  a  definite 
sense  of  fluctuation.  Frequently  the  two  conditions  of 
thickened  membrane  and  fluid  in  the  joint  co-exist,  and 
diagnosis  may  be  very  difficult. 

In  the  case  of  the  knee-joint,  riding  of  the  patella 
afibrds  an  excellent  means  of  detecting  fluid.  In  the 
case  of  other  joints,  the  sense  of  fluctuation  may  be 
sufficiently  marked  to  establish  the  correct  diagnosis. 

Irregular  local  thickening  of  synovial  membrane  is 
occasionally  seen  in  cases  of  syphilitic  joints.  The 
diagnosis  of  this  disease  affecting  a  joint  depends  more, 
however,  on  the  existence  of  characteristic  lesions  in 
the  skin,  mucous  membranes,  bones,  viscera,  and  else- 
where. 

The  presence  of  hard  local  thickenings,  nodules,  or 


254  SURGICAL    DIAGNOSIS. 

plates  of  bone  in  the  synovial  membrane  or  capsule  of 
a  joint  usually  indicates  chronic  rheumatoid  arthritis. 
The  diagnosis  is  confirmed  by  the  ridges  of  bone 
("lipping")  felt  at  the  margins  of  the  articular  carti- 
lages. 

(c)  Swelling  in  the  neighbourhood  of  the 
joint. 

The  examination  of  (i)  the  articular  ends  of  the 
bones  may  reveal  important  changes  associated  with 
joint  disease.  Indeed,  the  primary  seat  of  a  chronic 
inflammation  may  be  in  the  neighbouriog  epiphysis, 
the  joint  affection  being  secondary.  The  degree  of 
severity  of  a  case  of  chronic  joint  disease  may  to  a 
certain  extent  be  gauged  by  the  extent  of  implication 
of  the  neighbouring  bone  or  bones. 

(ii)  Swellings  in  the  soft  parts  near  a  joint  always 
demand  careful  examination  of  the  joint  itself.  Thus 
a  chronic  abscess  below  the  head  of  the  tibia  or  in  the 
upper  part  of  the  thigh  may  be  the  most  prominent 
feature  of  a  case  of  tuberculous  disease  of  the  knee  or 
hip  respectively. 

The  more  or  less  detached  synovial  cysts  connected 
with  chronic  rheumatoid  arthritis  have  already  been 
mentioned. 

III.  The  relative  position  of  the  bones  which 
enter  into  the  formation  of  a  joint  is  a  point  to  which 
attention  should  be  drawn.  As  a  general  rule,  in  all 
inflammatory  affections  of  joints  the  bones  are  held  in 
a  flexed  position,  the  position  of  greatest  ease.  Such 
is  the  case  with  disease  of  the  knee,  hip,  and  elbow. 
An  inflamed  wrist-joint,  on  the  other  hand,  is  usually 
kept  in  the  straight  extended  position. 

A  still  more  important  sign  of  joint  disease  indicating 


DISEASES    OF   JOINTS.  255 

destructive  disease  is  the  abnormal  relation  of  the  axes 
of  the  bones  to  one  another. 

The  threefold  displacement  of  the  tibia  upon  the 
femur  in  a  case  of  advanced  disease  of  the  knee  is  the 
best  example  that  can  be  given.  The  tibia  tends  to  be 
displaced  backwards  and  outwards,  and  also  to  be 
rotated  outwards.  The  displacement  of  the  trochanter 
upwards  and  backwards  towards  the  dorsum  ilii  in  a 
case  of  hip  disease  is  a  similar  example.  In  both  these 
cases  the  displacement  indicates  erosion  and  absorption 
of  bone,  due  either  to  caries  or  to  chronic  rheumatoid 
arthritis.  Very  great  absorption  and  deformity,  often 
with  free  mobility  and  little  or  no  pain,  should  suggest 
disease  of  the  central  nervous  system  as  a  cause  of  the 
joint  disease  (e.g.,  Charcot's  disease,  due  to  locomotor 
ataxy). 

IV.  Condition  of  the  muscles  surrounding  a 
joint. — The  muscles  around  a  joint  that  is  acutely  or 
subacutely  inflamed  are  in  a  state  of  spasm.  The 
contraction  of  the  muscles  serves  to  fix  the  joint  and  to 
keep  it  at  rest.  In  early  hip  disease,  for  example,  the 
fixity  of  the  joint,  from  spasm  of  the  muscles,  is  one 
of  the  most  important  signs. 

Wasting  of  the  muscles  may  be  due  to  mere  disuse, 
and  may  occur  in  the  case  of  any  joint  that  has  been 
kept  quiet  for  a  long  time.  Wasting  of  muscles  becomes, 
however,  animportant  sign  of  disease  when  it  setsin  early, 
and  is  quite  out  of  proportion  to  the  disuse  of  the  joint. 

Tuberculous  disease  of  a  joint  usually  produces 
marked  wasting  within  a  very  few  weeks  of  its  onset. 

Y,  The  movements  of  a  diseased  joint  may  be : 
(a)  Restricted  by  mere  spasm  of  muscles,  as  men- 
tioned in    the  preceding  paragraph,   due  to 


256  SURGICAL   DIAGNOSIS. 

active  disease  ;  by  voluntary  action  on  the  part 
of  tlie  patient,  as  in  hysteria,  or  from  dread  of 
pain,  real  or  imaginary ;  by  adhesions  around 
the  joint. 

Extra-articular  adhesions,  the  result  of  inflam- 
mation among  the  muscles  or  tendons,  may 
fix  a  joint  almost  completely. 
Adhesions  in  the  joint  due  to  previous 
inflammation  may  be  slight,  as  after  a  mild 
attack  of  synovitis,  or  may  be  so  extensive 
and  dense  as  to  firmly  unite  the  bones  together 
(fibrous ankylosis).  Ankylosis  in  children,  how- 
ever firm,  is  scarcely  ever  due  to  bony  union. 
But  in  ad  alts  joint  disease  that  has  been 
attended  by  destruction  of  articular  cartilages 
is  frequently  followed  by  true  bony  ankylosis. 
It  is  well  to  remember  that  in  rare  cases  bony  anky- 
losis may  follow  very  slight  and  insidious  disease  of  a 
joint. 

A  swelling  of  any  kind  in  the  neighbourhood  of  a 
joint  may  cause  restriction  of  movement  without  the 
joint  itself  being  diseased.  Thus,  a  tumour,  innocent 
or  malignant,  springing  from  the  lower  end  of  the 
femur  or  from  the  pelvis,  may  mechanically  prevent 
the  free  movement  of  the  neighbouring  joint.  In  such 
cases  the  diagnosis  is  made  partly  by  feeling  the  tumour 
itself,  and  partly  by  noticing  that  the  movement  of  the 
joint  is  perfectly  free  and  natural  up  to  a  certain  limit ; 
when  this  limit  has  been  reached,  further  movement  is 
suddenly  arrested  by  contact  with  the  tumour. 

(b)  Unnatural  mobility  of  a  joint  may  be  due  to 
mere  relaxation  of  ligaments,  tendons  or  muscles.  The 
joints  of  a  paralysed  limb  may  be  unduly  movable. 


DISEASES    OF   JOINTS.  257 

Long  continued  traction  upon  a  joint  may  cause 
looseness  of  the  joint  from  stretching  of  the  ligaments. 
Thus,  weight  extension  applied  for  many  months  or 
years  to  a  case  of  hip  disease  may  cause  considerable 
weakening  of  the  corresponding  knee,  especially  if  the 
weight  has  been  excessive,  or  if  care  has  not  been  taken 
to  apply  the  traction  to  the  thigh  rather  than  to  the 
leg  alone. 

Destructive  disease  of  the  bony  portions  of  a  joint, 
if  not  counteracted  by  inflammation  and  adhesions, 
causing  fixity,  may  lead  to  much  unnatural  mobility. 
Lateral  movement  at  the  elbow,  knee  or  ankle,  which,  in 
the  extended  position,  does  not  occur  normally,  is  an 
important  and  bad  sign  of  destruction  of  the  ends  of 
the  bones.  It  is  commonly  seen  in  advanced  tubercu- 
lous and  other  inflammatory  affections  of  these  joints, 
also  in  some  cases  of  chronic  rheumatoid  arthritis, 
attended  by  much  erosion  of  bone.  Unnatural  mobility 
of  a  joint  is  seen  in  its  most  marked  form  in  Charcot's 
disease,  where  the  erosion  of  bone  may  have  been  so 
extensive  that  the  joint  presents  a  flail-like  appearance, 
being  freely  and  painlessly  movable  in  all  directions. 

Grating  during  movement  of  a  joint  may  be  due 
merely  to  roughness  of  articular  cartilage,  as  in  rheuma- 
toid arthritis,  or  to  roughness  of  the  synovial  membrane, 
as  in  many  forms  of  dry  arthritis. 

In  its  most  marked  form,  however,  grating  indicates 
erosion  of  cartilage  and  exposure  of  the  underlying 
bone.  This  form  of  grating  is  common  in  advanced 
caries  of  the  joint,  in  rheumatoid  arthritis,  and  in 
Charcot's  disease. 


R 


CHAPTER    XXV. 

DISEASES  OF  THE  SPINE. 

In  investigating  a  case  of  disease  of  the  vertebral 
column  the  surgeon  should  direct  his  attention  especially 
to  the  following  points : 

The  shape  of  the  spine,  with  special  reference  to 

any  curvature  or  other  deformity. 
The  movements  of    the   spine,  noticing   whether 
they  are   restricted    in    any  way,  and   especially 
whether  they  are  attended  with  pain. 
The  existence  of  any  nervous  symptoms  indi- 
cating involvement  of  the  spinal  cord  or  of   the 
nerves  proceeding  from  it. 
The   existence  of   any  local   swelling   connected 
with  or  springing  from  the  vertebrae  (abscess,  new 
growth,  &c.). 

Shape  of  the  Spine. 

In  order  to  examine  thoroughly  the  shape  of  the 
spine  the  patient  should  be  undressed  and  the  whole 
spine  from  sacrum  to  occiput  thoroughly  exposed  to 
view.  In  the  case  of  young  children  it  is  best  that 
they  should  be  stripped  naked.  In  the  case  of  adults 
they  should  be  undressed  down  to  the  waist. 


DISEASES    OF    THE    SPINE.  259 

Women  and  others  who  are  sensitive  about  so  thorough 
an  exposure  of  the  body  should  then  be  told  to  put 
their  arms  through  the  sleeves  of  the  dress  or  coat,  so 
that  the  front  of  the  trunk  is  covered  while  the  whole 
of  the  back  is  nevertheless  freely  accessible  to 
examination. 

The  patient  should  at  first  be  examined  in  the  upright 
position,  whenever  this  is  possible. 

If  the  patient,  however,  is  suffering  from  a  painful 
or  acute  disease  of  the  spine,  it  may  be  undesirable  or 
impossible  to  make  him  adopt  the  vertical  position. 

The  examination  must  then  be  conducted  with  the 
patient  sitting  up  or  lying  upon  one  side.  In  extreme 
cases  it  may  be  necessary  to  make  the  examination  so 
as  to  ensure  the  least  possible  disturbance  of  the  spine  ; 
this  may  have  to  be  done  by  passing  the  hand  under 
the  spine  while  the  patient  lies  on  his  back. 

In  order  to  make  the  position  of  the  spinous  processes 
more  obvious,  it  is  a  good  plan  to  rub  the  fingers  two  or 
three  times  up  and  down  the  spine.  This  causes  tem- 
porary redness  of  the  skin  over  the  spinous  processes, 
and  renders  their  exact  position  more  readily  visible. 
The  fingers  should  be  passed  carefully  along  the  grooves 
on  either  side  of  the  spinous  processes,  and  any  irregu- 
larity or  tenderness  noted. 

A  general  backward  curvature  of  the  whole  spine, 
or,  at  any  rate,  of  the  dorsal  and  lumbar  portions  of  it 
(kyphosis),  is  common  in  young  children,  and  is  due 
merely  to  rickets  or  to  general  weakness.  It  is  usually 
easily  diagnosed  by  the  absence  of  pain,  and  by  the 
fact  that  the  spine  is  perfectly  flexible.  When  the 
child  is  lifted  up  by  the  shoulders  the  abnormal  curva- 
ture   disappears   entirely.     When  this    curvature  has 


2  6o  SURGICAL    DIAGNOSIS. 

existed  for  a  long  time  it  becomes  more  or  less  perma- 
nent, and  the  spine  loses  some  of  its  flexibility. 

The  question  may  then  arise  whether  the  curvature 
may  not  be  due  to  some  more  serious  disease,  such  as 
caries.  The  diagnosis  is  generally  made  by  noticing 
that  the  curve  is  a  general  and  uniform  one,  as  well  as 
by  the  absence  of  other  signs  characteristic  of  caries. 

The  general  backward  curvature  which  is  so  commonly 
seen  in  old  people,  and  which  is  due  mainly  to  a  pro- 
longed maintenance  of  the  stooping  position,  is  charac- 
terised by  a  similar  uniformity  in  the  curve,  but  in  these 
cases  the  spine  is  almost  always  rigid,  and  cannot  be 
restored  to  its  normal  position.  If  pain  occurs  in  such 
a  spine  it  is  often  due  to  chronic  rheumatoid  arthritis. 

Kyphosis  and  rigidity  of  the  spine  are  also  marked 
features  of  osteitis  deformans. 

A  general  curve  with  the  concavity  backwards  (lor- 
dosis) is  seen  only  in  the  lumbar  region,  and  is  not  an 
indication  of  any  disease  of  the  spine  itself.  It  usually 
means  some  affection  of  the  hip,  such  as  ankylosis  in  a 
flexed  position,  or  congenital  dislocation.  The  curvature 
of  the  spine  is  simply  secondary.  It  is  due  to  the  rota- 
tion of  the  pelvis  round  a  horizontal  transverse  axis, 
which  is  necessary  before  the  flexed  thigh  can  be 
brought  into  the  vertical  position. 

The  characteristic  feature  of  the  curvature  due  to 
caries  of  the  spine  is  the  point  or  angle  seen  at  the 
most  prominent  part  of  the  curve.  A  definite  sharp 
prominence  in  the  line  of  the  spine  indicates  that  the 
spine  is  sharply  bent.  A  sharp  bend  in  the  spine  can 
be  produced  only  by  absorption  of  the  bodies  of  a  limited 
number  of  vertebrae.  Such  absorption  and  destruction 
of  bone  is  caused  only  by  tuberculous  caries  or  by  the 


DISEASES    OF   THE    SPINE.  261 

much  rarer  malignant  disease.  The  curvature  produced 
by  malignant  disease  is  indistinguishable,  by  the  shape 
of  the  spine  alone,  from  that  which  is  caused  by  tubercle. 
It  is,  however,  generally  not  difficult  to  arrive  at  a 
correct  diagnosis  by  observation  of  the  greater  severity 
of  the  pain,  by  the  short  history,  by  the  age  of  the  patient, 
and  by  other  signs  of  malignancy.  Caries  of  the  spine 
starting  at  an  advanced  age  is  sometimes  mistaken  for 
malignant  disease,  and  vice  versa. 

In  some  few  cases  of  chronic  caries  involving  a  con- 
siderable number  of  vertebrae,  the  sharp  angle  above 
mentioned  is  not  present.  Several  spinous  processes 
project  prominently  backwards  and  form  a  rounded 
protuberance.  Such  cases  may  at  first  present  some 
resemblance  to  scoliosis  (so-called  lateral  curvature), 
but  may  be  distinguished  by  the  greater  and  more  local 
degree  of  curvature,  and  usually  by  the  abnormal 
straightness  of  the  rest  of  the  spine  above  and  below 
the  projection. 

In  some  cases,  on  the  other  hand,  the  amount  of  cur- 
vature may  be  extremely  slight,  and  may  consist  in  little 
more  than  a  slight  prominence  of  a  single  vertebra.  A 
single  prominent  vertebra,  especially  if  associated  with 
rigidity  or  unnatural  straightness  of  the  neighbouring 
portion  of  the  spine,  is  highly  suggestive  of  absorption 
of  the  bodies  of  one  or  more  vertebrae,  that  is,  of 
tuberculous  caries  (or  possibly  malignant  disease). 

True  lateral  curvature  of  the  spine  is  rare,  and  is  seen 
chiefly  in  cases  in  which  one  side  of  the  chest  has 
recently  become  contracted  as  the  result  of  pleurisy  or 
empyema. 

The  common  deformity  to  which  the  name  of  *'  lateral 
curvature "  is  usually  applied  is  not  a  true  or  simple 


262  SURGICAL   DIAGNOSIS. 

lateral  curvature,  but  a  combination  of  a  certain  amount 
of  lateral  curving  with  a  great  deal  of  twisting  of  the 
vertebral  column  (hence  the  name  scoliosis). 

Simple  kyphotic  curvatures  unattended  by  rigidity, 
as  v^ell  as  pure  lateral  curvatures  in  young  people,  are 
apt  to  pass  into  a  condition  of  scoliosis.  In  scoliosis 
the  line  formed  by  joining  the  tips  of  all  the  spinous 
processes  shows  more  or  less  deviation  from  the  vertical. 
It  is  well  to  remember  that  this  line  does  not  repre- 
sent the  true  amount  of  lateral  curvature,  since  the 
rotation  of  the  vertebra3  tends  to  throw  the  bodies 
outwards  and  the  spinous  processes  inwards  towards 
the  middle  line.  The  apparent  curvature,  as  shown 
by  the  spinous  processes,  is  therefore  less  than  the 
real  one. 

In  the  diagnosis  of  scoliosis,  evidence  of  this  rotation 
should  be  looked  for.  The  transverse  processes  on  the 
convex  side  of  the  curve  are  more  prominent,  being 
rotated  backwards,  while  those  on  the  concave  side, 
which  are  rotated  forwards,  are  less  prominent. 

The  ribs  follow  the  dorsal  vertebraa  to  which  they  are 
attached,  and  are  rotated  backwards  on  the  convex,  for- 
wards on  the  concave,  side  of  the  curve.  Deformity  of 
the  chest  and  alteration  in  the  shape  of  the  ribs  them- 
selves are  necessarily  produced  by  the  same  rotation. 
The  forward  displacement  of  the  ribs  sometimes  leads 
the  patient  to  complain  primarily  of  a  "  lump  in  the 
chest,"  or  even  of  a  "tumour  in  the  breast,"  rather 
than  of  anything  wrong  with  the  spine,  of  which  she 
may  be  wholly  unaware.  Inspection  by  means  of  the 
Rontgen  rays  affords  a  good  means  of  seeing  the  actual 
amount  of  lateral  curvature  that  is  present. 

The   diagnosis  of    a   well-marked   case  of   scoliosis 


DISEASES    OF   THE    SPINE.  263 

presents  no  difficulty.  Evidence  of  the  rotation  above 
mentioned  is  sufficient  to  establish  the  diagnosis. 

In  some  few  cases  scoliosis  leads  to  the  complaint  of 
pain,  and  this  pain  may  lead  to  the  suspicion  of  caries. 
The  pain,  however,  is  rarely  more  than  a  feeling  of 
weakness  or  discomfort,  and  is  quite  unlike  the  more 
severe  pain  usually  felt  in  the  acute  stages  of  caries. 

A  difficulty  sometimes  occurs  in  diagnosis  in  those 
cases  in  which  scoliosis  has  followed  upon,  and  coexists 
with,  caries ;  in  these  cases  careful  examination  will 
generally  reveal  some  of  the  special  signs  and  symptoms 
indicative  of  caries. 


Movements  of  the  Spine. 

The  spine  in  health  is  a  flexible  structure,  capable  of 
bending  freely  in  the  anterio-posterior  direction,  and 
permitting  a  considerable  amount  of  rotation.  With 
advancing  age  the  spine  tends  to  become  less  flexible. 
To  test  the  movements  of  the  spine  the  patient  should 
stand  with  his  back  to  the  surgeon,  who  grasps  the 
pelvis  firmly  with  both  hands.  The  patient  should  then 
bend  the  body  first  forwards,  then  backwards,  as  far  as 
possible,  and  then  rotate  it,  looking  first  over  one 
shoulder  then  over  the  other.  Or  the  patient  may  be 
seated  on  a  couch  ;  the  surgeon,  seated,  places  one  hand 
firmly  against  the  sacrum,  and  tells  the  patient  to  bend 
backwards  until  the  head  touches  the  couch ;  then  for- 
wards until  the  head  is  between  the  knees.  The  per- 
fectly healthy  spine  should  thus  be  thrown  into  a 
regular  curve,  concave  and  convex  respectively,  back- 
wards. 

Another  method  of  testing  the  freedom  of  movement 


264  SURGICAL   DIAGNOSIS. 

of  the  spine  is  to  direct  the  patient,  standing  with  the 
heels  together,  to  pick  up  any  small  object,  such  as  a 
book  or  a  bunch  of  keys,  from  the  floor,  and  to  observe 
how  he  does  this,  whether  easily  and  naturally  or  with 
hesitation,  stiffly,  slowly,  and  carefully.  This  is  a  test 
not  so  much  of  deformity  of  the  spine  as  of  painful 
rigidity,  and  is  chiefly  useful  in  the  detection  of  early 
acute  caries. 

The  spine  may  be  stiff  from  actual  ankylosis  of  the 
vertebrae,  as  in  rheumatoid  arthritis  or  old  caries ;  or 
from  rigidity  and  spasm  of  muscles,  as  in  all  cases  of 
acute  or  subacute  inflammatory  and  other  painful 
diseases  of  the  spine. 

Local  tenderness  on  percussion  is  sometimes  a  valu- 
able indication  of  caries  of  the  spine  in  the  early  stages 
before  actual  deformity  has  presented.  Of  local  sensi- 
tiveness to  heat,  as  applied  by  a  hot  sponge,  the  same 
may  be  said. 

Nervous  Symptoms. 

The  intimate  connection  between  the  vertebral 
column  and  the  spinal  cord  and  nerves  contained  within 
it  naturally  leads  in  many  cases  to  the  production  of 
nervous  symptoms. 

Any  disease  which  causes  absorption  and  consequent 
falling  together  of  vertebral  bodies  (i.e.,  tuberculous 
caries  and,  more  rarely,  malignant  disease),  tends  to 
diminish  the  size  of  the  intervertebral  foramina  through 
which  the  corresponding  spinal  nerves  pass.  It  is  the 
irritation  of  spinal  nerves  thus  produced  that  is  the 
main  cause  of  the  peripheral  pain  which  is  so  common 
a  symptom  of  caries  of  the  spine.     The  pain  is  referred 


DISEASES    OF   THE    SPINE.  265 

to  the  peripheral  distribution  of  the  spinal  nerves  that 
are  thus  involved  at  their  proximal  ends.  Hence  the 
pain  at  the  back  of  the  head  (occipital)  in  upper  cer- 
vical caries,  the  pain  at  the  front  of  the  chest  in  upper 
dorsal,  in  the  front  of  the  abdomen  in  lower  dorsal 
caries,  the  pains  about  the  hips  and  down  the  thighs  in 
caries  of  the  lumbar  and  sacral  regions. 

A  child  who  complains  of  persistent  stomach  ache,  for 
which  no  abdominal  cause  can  be  discovered,  should 
always  be  suspected  to  have  disease  of  the  spine,  and  a 
thorough  examination  of  that  part  should  follow. 

Malignant  disease  is  likely  to  involve  spinal  nerves 
or  nerve  roots,  either  by  pressure  or  by  direct  infil- 
tration. The  pain  produced  is  usually  excruciating 
and  persistent,  being  much  more  severe  than  that  of 
tuberculous  caries.  It  is,  moreover,  less  likely  to  be 
relieved  by  the  recumbent  position. 

Mere  bending  of  the  spine  without  actual  disease  of 
the  bones  does  not  usually  affect  either  the  spinal  cord 
or  the  nerves. 

Nor  does  the  curve  of  caries,  as  a  rule,  cause  nervous 
symptoms  referable  to  pressure  on  the  spinal  cord, 
because  the  curvature  is  produced  slowly,  and  the 
cord  has  time  to  accommodate  itself  to  the  altered 
shape  of  the  vertebral  canal.  When  symptoms  of 
pressure  upon  the  cord  do  occur  in  connection  with 
caries,  they  are  almost  invariably  produced  by  the 
pressure  of  inflammatory  products  upon  the  spinal  cord 
and  not  by  the  pressure  of  bone. 

The  soft  tuberculous  matter  tends  to  be  squeezed 
backwards  against  the  cord  by  the  pressure  of  super- 
incumbent vertebras. 

The  beneficial  effect  of  rest  in  the  horizontal  position 


2  66  SURGICAL   DIAGNOSIS. 

upon  the  pressure  symptoms  in  most  cases  in  which 
these  symptoms  have  only  recently  supervened  is  well 
known. 

Occasionally  pressure  upon  the  cord  is  produced  by 
a  definite  chronic  abscess  within  the  vertebral  canal, 
between  the  body  of  the  vertebra  and  the  theca 
vertebralis. 

Occasionally  a  spread  of  inflammation  from  the  bones 
to  the  meninges,  cord  and  nerves  is  the  cause  of  the 
nervous  symptoms. 

In  the  case  of  fracture  of  the  spine  causing  paraplegia 
the  case  is  different.  Here  it  is  almost  always  the  bone 
itself  that  presses  upon  or  cuts  into  the  spinal  cord  ;  or 
the  cord  may  be  compressed  by  the  effusion  of  blood 
into  the  vertebral  column. 

The  earliest  and  most  common  symptoms  of  pressure 
upon  the  cord  are  exaggeration  of  tendon  reflexes  (knee 
jerks)  if  the  seat  of  pressure  is  above  the  lumbar 
enlargement,  and  paraplegia.  The  latter  may  consist 
merely  of  slight  weakness  of  the  legs,  or  may  be  of  any 
degree  of  severity  up  to  complete  paralysis  of  the  lower 
limbs.  Sensation  is  retained,  as  a  rule,  long  after 
motor  paralysis  has  become  complete. 

Malignant  disease,  like  caries,  produces  also  ex- 
aggeration of  reflexes  and  paralysis  of  the  limbs.  But 
the  disease  being  progressive,  the  nervous  symptoms 
are  not  likely  to  diminish  as  the  disease  advances. 
Nor  are  they  so  likely  to  be  favourably  influenced  by 
the  adoption  of  the  recumbent  posture.  Malignant 
disease  is  also  more  likely  to  pick  out  individual  nerves 
and  nerve-roots,  and  severe  pain  is  almost  always  asso- 
ciated with  the  other  symptoms. 

It  need  scarcely  be  said  that  disease,  whether  tuber- 


DISEASES    OF    THE    SPTNE.  267 

culous  or  malignant,  when  affecting  the  lumbar  en- 
largement or  the  nerves  below  this,  does  not  cause 
exaggeration  of  reflexes,  but  rather  diminution  of 
them. 


Local  Swellings. 

Local  swellings  in  connection  with  diseases  of  the 
spine    are   practically    of   two    classes  :    those    which 
are  inflammatory,  and  those  which  are  new  growths. 
Besides  these  there  are   certain   congenital  swellings 
such    as  spina  bifida,  the  diagnosis  of    which   usually 
presents  no  difficulty.     Tumours  springing  from  the 
spine  seldom  form  swellings  that  can  be  seen  or  felt 
from  the  back  until  a  late  stage  of  the  disease  has 
been  reached,  when  the  diagnosis  is  no  longer  doubtful. 
Nearly   all   tumours    of  the    spine    originate    in  the 
bodies  of   the  vertebrse.     In  their  growth   they  may 
extend    backwards    into    the    spinal     canal,    causing 
symptoms  of  pressure  upon  the   spinal  cord,  or  they 
may  project  laterally  or  anteriorly,  pressing  upon  the 
structures  nearest  to  them.     The  pressure  effects  are 
similar   to  those  of  the  much  more  common  inflam- 
matory swellings,  which  may  now  be  considered. 

In  every  case  of  suspected  caries  of  the  spine  a 
careful  examination  should  be  made  to  ascertain  whether 
an  abscess  exists  or  not.  It  must  be  remembered  that 
an  abscess  in  connection  with  caries  of  the  spine  may 
form  very  insidiously  and  give  rise  to  no  acute 
symptoms,  such  as  pain  or  elevation  of  temperature. 

If  the  abscess  makes  its  way  to  the  back  of  the  spine 
it  may  form  an  obvious  swelling,  situated  usually  some- 
what on  one  side  of  the  middle  line. 


2  68  SURGICAL   DIAG>fOSIS. 

Such  an  abscess  does  not  usually  present  much 
difficulty  in  diagnosis. 

But  if  the  evidence  of  disease  of  the  spine  is  not 
plain,  a  deep-seated  abscess  in  this  region  may  be  mis- 
taken for  a  fatty  tumour  or  other  growth.  This  is 
especially  likely  to  occur  if  the  abscess  presents  over 
the  ribs  at  some  little  distance  from  the  spine.  Cai^ 
may  have  to  be  taken  to  distinguish  the  spinal  abscess 
from  abscess  connected  with  local  disease  of  a  rib  and 
from  an  empyema  pointing  backwards.  It  need  scarcely 
be  said  that  empyema  is  occasionally  secondary  to  caries 
of  the  dorsal  spine. 

An  abscess  originating  in  the  cervical  spine  may 
remain  in  front  of  the  vertebras,  and  in  this  situation  it 
may  be  detected  by  careful  examination  of  the  back 
of  the  pharynx,  by  direct  inspection,  or  by  palpation 
with  the  fiuger.  Or  if  a  little  lower  down  out  of 
reach  of  the  finger  in  the  pharynx,  its  presence  may  be 
detected  by  the  pressure  it  exerts  upon  the  oesophagus 
or  pharynx,  causing  difficulty  in  swallowing  ;  or  even 
by  the  displacement  forwards  of  the  larynx  and 
trachea.  Such  abscesses  can,  however,  usually  be 
detected  by  careful  deep  palpation  from  the  outside, 
the  larynx  and  trachea  being  pushed  gently  to  one 
side. 

A  post-pharyngeal  abscess  connected  with  caries  of 
the  spine  may  be  simulated  by  an  abscess  due  to  some 
other  cause,  such  as  a  foreign  body  (pin  or  fishbone). 

Not  very  uncommonly  does  the  pus  from  a  suppu- 
rating tonsil  make  its  way  behind  the  pharynx  and 
present  as  a  post-pharyngeal  abscess,  causing  probably 
much  difficulty  both  in  swallowing  and  breathing; 
such  an  abscess  is,  however,  never  situated  strictly  in 


DISEASES    OF    THE    SPINE.  269 

the  middle  line,  being  always  more  or  less  on  the  side 
of  the  tonsil  from  which  it  came.  Gummata  in  the 
soft  tissues  behind  the  pharynx  and  new  growths 
springing  from  the  vertebrae  or  elsewhere  occasionally 
simulate  abscesses  of  spinal  origin.  Abscesses  connected 
with  disease  of  the  cervical  spine  seldom  remain  in 
front  of  the  vertebral  bodies,  but  tend  to  make  their 
way  laterally  to  the  side  of  the  neck,  where  they  can 
be  detected  by  careful  deep  palpation.  Such  abscesses 
are  most  likely  to  be  confused  with  abscesses  due  to 
tuberculous  glands.  The  difficulty  in  diagnosis  may 
be  much  increased  in  those  cases  in  which  the  spinal 
symptoms  are  ill-marked,  and  in  those  in  which  enlarge- 
ment of  lymphatic  glands  secondary  to  the  spinal 
caries  also  exists. 

In  every  case  of  suspected  caries  of  the  upper  dorsal 
or  lower  cervical  spine,  careful  palpation  should  be 
made  at  the  root  of  the  neck,  just  above  the  sternum 
on  either  side  of  the  trachea.  The  abscess  that  forms 
in  connection  with  the  dorsal  spine  may  be  very  difficult 
to  detect  if  it  does  not  pass  either  backwards,  or  down- 
wards into  the  lumbar  region.  Careful  auscultation 
and  percussion  will,  however,  sometimes  reveal  the 
presence  of  an  abscess  at  the  side  of  the  dorsal  spine 
if  sufficiently  large.  Or  it  may  be  suspected,  if  not 
actually  diagnosed,  by  the  pressure  it  exerts  upon  the 
oesophagus.  Or  it  may  involve  the  pleura,  and  thus 
give  rise  to  physical  signs. 

All  spinal  abscesses  have  a  tendency  to  gravitate 
downwards.  In  every  case  of  spinal  caries,  therefore, 
deep  palpation  of  the  lumbar  region  should  be  made. 
Even  if  no  actual  collection  of  pus  can  be  felt,  the 
contraction  of  a  psoas  muscle,  shown  by  the  flexion  of 


270  SURGICAL    DIAGNOSIS. 

the  hip,  may  lead  to  a  strong  suspicion  of  abscess. 
In  the  lumbar  region  a  perinephritic  abscess  often 
closely  resembles  that  of  spinal  caries. 

Abscess  connected  with  sacral  or  lower  lumbar  caries 
may  be  detected  by  careful  examination  per  rectum. 

Abscesses  connected  with  spinal  caries  may  pass 
through  the  sacrosciatic  foramen  into  the  buttock, 
simulating  an  abscess  connected  with  the  hip-joint,  or 
into  the  perineum,  forming  a  very  serious  variety  of 
ischiorectal  abscess.  The  occurrence  of  a  spinal  abscess 
in  the  upper  part  of  the  thigh  or  even  still  lower  down 
is  too  well  known  to  require  more  than  a  passing 
mention. 

An  impulse  on  coughing,  which  is  a  common  feature 
of  spinal  abscesses  which  have  made  their  way  to  the 
back,  loin,  thigh,  or  elsewhere,  merely  indicates  a 
connection  with  the  interior  of  the  thorax  or  abdomen, 
and  is,  of  course,  not  peculiar  to  spinal  abscesses. 

The  use  of  theKontgen  rays  in  connection  with  scoliosis 
has  already  been  mentioned  on  p.  262.  They  are  also 
often  of  very  great  use  in  the  diagnosis  of  caries  of  the 
spine  and  of  malignant  disease.  Absorption  of  bone  and 
deposition  of  new  bone  may  be  readily  made  out  by 
their  means.  The  difficulty  of  obtaining  accurate 
X-ray  photographs  of  deeply  seated  structures  such  as 
the  lumbar  spine  has  perhaps  led  to  their  employment 
for  the  diagnosis  of  caries  of  the  spine  to  a  less  extent 
than  is  desirable.  In  many  doubtful  cases  of  caries  of 
the  spine  without  marked  deformity,  absolute  and  clear 
proof  of  the  nature  of  the  disease  is  at  once  afforded 
by  an  X-ray  photograph. 


CHAPTER  XXVI. 

DIAGNOSIS  OF  ENLARGED  LYMPHATIC 

GLANDS. 

The  diagnosis  of  the  lympliatic  glandular  nature  of  a 
swelling  or  group  of  swellings  generally  presents  but 
little  difficulty.  The  situation  of  the  swelling  or 
swellings  in  some  part  where  lymphatic  glands  are 
known  normally  to  occur  naturally  helps  in  the 
diagnosis.  Thus,  the  anterior  and  posterior  triangles 
of  the  neck,  the  axilla,  the  front  and  inner  part  of  the 
upper  arm  just  above  the  inner  condyle,  the  groin  and 
the  popliteal  space  are  the  regions  in  which  glandular 
swellings  usually  occur.  Enlargement  of  the  more 
deeply  placed  glands  in  the  interior  of  the  body,  such 
as  the  mediastinal  and  lumbar  glands,  present  greater 
difficulties  in  diagnosis  on  account  of  their  inacces- 
sibility. 

Multiplicity  is  another  important  feature  of 
enlarged  glands.  Diseases  that  affect  lymphatic  glands 
usually  cause  enlargement  of  several  of  them.  A  chain 
of  little  swellings  in  one  of  the  above-mentioned  situa- 
tions is  almost  certain  to  be  lymphatic  glandular.  Even 
when  the  disease  at  first  sight  appears  to  consist  of  a 
single  swelling,  it  will  generally  be  found,  on  careful 
examination,  that  similar  but  smaller  swellings  exist  in 


272  SURGICAL   DIAGNOSIS. 

close  proximity  to  the  larger  one,   and  will  give  a  clue 
to  its  nature, 

A  single,  small,  rounded,  or  oval  swelling  in  a  situa- 
tion where  glands  normally  occur  is  probably  a  gland, 
unless  there  is  a  distinct  reason  to  the  contrary. 

A  large  mass  composed  of  a  number  of  glands  more 
or  less  matted  together  is  generally  to  be  diagnosed  by 
its  lobulated  appearance,  even  if  neighbouring  separate 
glands  cannot  be  detected.  There  are,  however,  rare 
cases  in  which  tumours  not  connected  with  glands 
occur  in  groups  or  chains.  The  multiple  neuro-fibro- 
mata  of  the  neck,  connected  with  the  cervical  and 
brachial  plexuses,  may  be  cited  as  an  example. 

Lobulated  tumours  such  as  fibro-lipomata  occasionally 
simulate  masses  of  enlarged  glands.  They  can  usually 
be  distinguished  by  their  softness,  by  the  absence  of 
inflammatory  adhesions  and  by  the  absence  of  neigh- 
bouring isolated  glands.  In  many  cases  the  diagnosis 
of  the  glandular  nature  of  the  swelling  is  made  less 
from  the  physical  character  of  the  swelling  than  from 
the  concomitant  inflammation.  Thus  an  acute  in- 
flammatory swelling  in  the  groin  or  axilla  may  present 
merely  the  characters  of  an  abscess.  That  the  abscess 
is  due  to  inflammation  of  glands  might  be  inferred, 
however,  from  the  existence  of  an  inflamed  sore  upon 
the  foot  or  hand,  the  starting-point  of  lymphatic 
absorption. 

In  investigating  the  nature  of  any  supposed  glandular 
swelling  it  cannot  be  too  strongly  insisted  upon  that  a 
careful  examination  should  be  made  of  the  neighbour- 
ing skin  and  mucous  membrane,  from  which  glands  in 
this  situation  normally  derive  their  lymphatics. 

Thus  a  sore  upon  the  head  or  face  may  be  the  cause 


ENLARGED    LYMPHATIC    GLANDS.  273 

of  cervical  glandular  enlargement ;  upon  the  arm,  chest, 
or  back,  of  axillary  enlargement ;  upon  the  abdomen, 
perineum,  genital  organs,  lower  limb,  &C.5  of  enlarge- 
ment of  glands  in  the  groin.  Disease  upon  the  cutaneous 
surface  of  the  body  is  less  likely  to  escape  observation 
than  disease  situated  upon  the  mucous  membrane  of 
internal  cavities.  How  often  do  we  see  simple, 
tuberculous,  or  malignant,  glandular  swellings  of 
the  neck,  the  primary  cause  of  which  lies  in  a 
hitherto  undetected  affection  of  the  mouth,  pharynx  or 
oesophagus ! 

Although  some  glandular  swellings  are  due  to  disease 
primarily  affecting  the  glands  themselves,  yet,  in  the 
vast  majority  of  cases,  the  primary  cause  is  to  be  sought 
elsewhere.  Frequently,  too,  the  treatment  of  the 
glands  resolves  itself  into  the  treatment  of  the  primary 
cause. 

Extreme  hardness  of  the  glands  denotes  either 
malignant  or  very  chronic  inflammation.  The  hardest 
of  all  glands  are  those  which  have  become  calcified. 
The  long  history  will  usually  indicate  the  true  nature 
of  the  affection.  Chronically  inflamed  but  not  calcified 
glands  tend  to  be  hard  in  proportion  to  the  amount  of 
fibrosis  that  they  have  undergone.  Acutely  inflamed 
glands  may  be  hard,  but  are  easily  diagnosed  by  the 
pain  and  tenderness. 

A  form  of  glandular  enlargement  attended  by  con- 
siderable induration  but  of  very  short  duration  is  that 
which  is  foand  accompanying  the  primary  sore  of 
syphilis.  The  resemblance  between  submaxillary 
glands  of  this  nature  and  those  of  malignant  origin 
occasionally  presents  some  difficulty,  especially  in 
elderly   people.     The   diagnosis   has   to   be   made   by 


274  SURGICAL   DIAGNOSIS. 

careful  attention  to  the  history  as  well  as  to  the  characters 
of  the  local  sore  on  the  lip,  tongue,  or  elsewhere. 

Although  malignant  glands  are  almost  always  hard, 
there  are  cases  in  which  such  glands  are  very  soft. 
Thus  the  glands  of  lymphosarcoma  are  sometimes  so 
soft  as  to  resemble  broken-down  tuberculous  glands. 
Such  glands  have  even  been  known  to  be  incised,  under 
the  mistaken  idea  that  an  abscess  was  present. 

Again,  large  masses  of  secondary  epithelioma  may 
be  so  broken  down  and  soft  as  to  simulate  abscess. 

The  resemblance  to  abscess  is  very  much  greater  if 
to  the  growth  a  septic  element  is  superadded.  Primary 
epitheliomata  of  the  mouth,  pharynx,  penis,  and  other 
parts  which  are  likely  to  have  a  very  foul  surface  are 
especially  likely  to  cause  sepsis  and  consequent  break- 
ing down  of  the  secondary  glands. 

Chronically  enlarged  glands  that  have  rapidly 
enlarged  and  softened  are  very  likely  to  contain  pus, 
even  when  none  of  the  more  obvious  symptoms  of 
suppuration  are  present.  Tuberculous  glands  in  the 
neck,  for  example,  are  often  found  to  coiitain  pus  in 
the  interior  of  them. 

The  question  often  arises  whether  a  given  swelling 
of  the  neck  is  a  mass  of  glands  or  whether  it  is  a 
chronic  abscess.  The  question  is  to  be  answered 
partly  by  the  softness  and  feeling  of  fluid  within  the 
lump,  partly  by  accurate  observation  of  its  situation. 
A  swelling,  for  instance,  which  lies  partly  over  and 
partly  under  the  sterno-mastoid,  curviug  round  its 
anterior  or  posterior  border,  is  probably  an  abscess, 
certainly  not  a  single  gland. 

Glands  that  are  the  seat  of  simple  septic  inflamma- 
tion generally  either  rapidly  subside  when  the  primary 


ENLARGED    LYMPHATIC    GLANDS.  275 

source  of  infection  has  been  treated,  or  else  they 
suppurate.  In  either  case  the  acuteness  of  the 
symptoms  usually  suffices  for  a  diagnosis. 

The  more  chronic  forms  of  inflammation  are  usually 
due  to  tubercle  or  syphilis.  The  diagnosis  has  to  be 
made  mainly  by  the  evidence  of  other  manifestations 
of  the  disease  elsewhere.  Tuberculous  glands  show  a 
marked  tendency  to  progress  slowly  and  comparatively 
painlessly  and  to  suppurate.  Syphilitic  glands  have 
much  less  tendency  to  suppurate.  When  superficial, 
the  former  have  a  marked  tendency  to  cause  a  bluish 
purple  discoloration  of  the  overlying  skin. 

Lymphadenomatous  glands  are  generally  to  be  diag- 
nosed by  their  steady  increase  in  size  and,  except  in  the 
latest  stages,  by  little  or  no  tendency  either  to  become 
adherent  to  each  other  or  to  neighbouring  parts,  or  to 
suppurate. 

A  mass  composed  of  a  number  of  glands  of  con- 
siderable size  which  move  freely  upon  each  other  and 
upon  surrounding  parts  is  much  more  likely  to  be 
lymphadenomatous  than  tuberculous. 

In  some  cases  of  doubt  as  to  the  nature  of  a  group 
of  enlarged  glands  it  may  be  desirable  to  remove  a 
gland  and  subject  it  to  microscopical  or  bacteriological 
examination. 


CHAPTER  XXVII. 

DIAGNOSIS  OF  ANEURISM. 

An  aneurism  is  diagnosed  partly  by  its  physical  signs, 
partly  by  the  symptoms  to  which  it  gives  rise. 

When  the  aneurism  is  easily  accessible  to  direct 
examination,  as  in  the  case  of  an  aneurism  of  one  of  the 
limbs,  the  physical  signs  are  of  most  importance.  If 
the  aneurism,  however,  be  deeply  seated,  as  within  the 
cranium  or  in  the  thorax  or  abdomen,  where  its 
physical  characters  are  less  easily  observed,  then  the 
symptoms  to  which  it  gives  rise,  and  especially  the 
pressure  symptoms,  become  proportionately  of  more 
importance. 

An  aneurism,  being  a  local  dilatation  of  an  artery, 
must  be  situated  in  the  line  of  an  artery.  As  most  aneu- 
risms, with  the  exception  of  cerebial  and  pulmonary 
aneurisms,  spring  from  large  arteries,  the  situation 
of  the  tumour  in  or  close  to  the  line  of  some  known 
artery  is  the  first  point  in  the  diagnosis.  The 
tumour,  moreover,  being  attached  to  the  artery  cannot 
be  separated  from  it.  Containing  as  it  does,  in  nearly 
all  cases,  fluid  blood  in  direct  communication  with  that 
of  the  interior  of  the  artery  from  which  it  springs, 
an  aneurism  pulsates.  The  pulsation  is  expansile. 
In  this  respect  it  differs  from   that  which   is  merely 


DIAGNOSIS    OF   ANEURISM.  277 

communicated  to  a  tumour  lying  in  direct  contact 
with  a  large  artery.  Many  tumours  of  the  neck  which 
are  not  aneurismal  pulsate  markedly,  owing  to  the 
presence  of  the  underlying  carotid  artery.  If  such  a 
tumour  be  soft,  or  if  it  contain  fluid,  it  may  easily  be 
mistaken  for  an  aneurism. 

Sarcomata  and  other  tumours  sometimes  have  large 
arteries  running  over  them.  The  pulsation  of  such 
arteries  thus  superficially  placed  may  be  very  easily 
felt,  and  may  lead  to  error  if  care  be  not  taken  to 
observe  whether  the  pulsation  is  expansile  and  involves 
the  whole  of  the  tumour. 

Chronic  and  slight  distension  of  the  hip-joint  from 
rheumatoid  arthritis  sometimes  lifts  up  the  common 
femoral  artery  and  forms  a  tumour  which  apparently 
pulsates  and  which  may  be  mistaken  for  an  aneurism  of 
that  artery. 

In  some  few  cases  a  malignant  tumour  may  be  so 
permeated  with  large  arteries  that  a  certain  amount  of 
true  expansile  pulsation  exists  in  it.  The  amount  of 
expansile  pulsation  in  such  cases  is,  however,  so  very 
slight  that  it  ought  not  to  lead  to  error.  Besides,  there 
are  usually  other  points  about  the  case  which  serve  to 
make  the  diagnosis  clear. 

The  amount  of  expansile  pulsation  in  an  aneurism 
naturally  varies  according  to  the  fluidity  of  the 
aneurismal  contents.  An  aneurism  with  a  thin  wall 
and  almost  wholly  fluid  contents  pulsates  strongly. 
One  which  is  nearly  or  wholly  filled  up  with  clot  pul- 
sates little  or  not  at  all.  A  cured  aneurism,  which  has 
shrunken  in  size  and  is  represented  merely  by  a  mass 
of  partially  absorbed  blood  clot  and  connective  tissue, 
may   present  great  difficulties   in   diagnosis.     It  may 


278  SURGICAL   DIAGNOSIS. 

easily   be  mistaken  for    a  fibrous   or   other   innocent 
tumour. 

An  aneurism  may  become  inflamed,  and  if  the  skin 
over  it  be  reddened,  tender  and  perhaps  oedematous, 
the  resemblance  to  an  abscess  may  be  considerable. 
The  similarity  may  be  increased  by  the  fact  that  the 
inflammation  of  the  aneurism  is  likely  to  lead  to  clotting 
of  the  blood  within  it,  thus  rendering  the  pulsation 
less  obvious.  Cases  are  by  no  means  unknown  in  which 
such  aneurisms  have  been  incised  in  mistake  for 
abscess,  sometimes  with  disastrous  results. 

Occasionally  an  abscess  will  erode  the  wall  of  an 
artery.  Blood  then  passes  into  the  abscess  cavity,  and 
a  false  aneurism  is  formed.  If  the  previous  suppura- 
tion has  led  to  the  formation  of  scars  over  the  tumour, 
the  resemblance  of  such  a  tumour  to  a  simple  abscess 
is  heightened. 

Aneurisms  usually  produce  a  systolic  bruit  which 
forms  an  important  diagnostic  sign.  It  varies  much  in 
degree  and  intensity,  and  may  be  completely  absent. 
It  is  simulated  by  the  factitious  bruit  produced  by  the 
pressure  of  any  tumour  upon  a  neighbouring  artery. 
Tumours  at  the  root  of  the  neck,  e.g.,  thyroid  cysts, 
often  present  loud  bruits  from  the  pressure  which  they 
exert  upon  surrounding  large  vessels. 

Such  factitious  bruits  are  easily  produced  in  normal 
arteries,  such  as  the  abdominal  aorta  or  the  common 
femoral,  by  pressing  lightly  upon  them  with  the  stetho- 
scope. 

A  bruit  transmitted  from  a  valvular  lesion  of  the 
heart  may  also  be  mistaken  for  an  aneurismal  bruit. 
An  aneurismal  bruit  is  usually  loud  and  harsh,  but  has 
in  itself  nothing  quite  characteristic. 


DIAGNOSIS   OF   ANEURISM.  279 

Another  important  physical  sign  of  an  aneurism  is  that 
the  tumour  diminishes  in  size  when  pressure  is 
made  upon  the  artery  supplying  it.  The  extent  to 
which  the  tumour  can  thus  be  diminished  in  size  will 
depend  upon  the  amount  of  fluid  blood  within  it,  and 
also  to  a  certain  extent  upon  the  thinness  and  com- 
pressibility of  the  aneurismal  wall. 

When  the  pressure  is  taken  off"  the  artery,  the 
aneurism  speedily  returns  to  its  original  size,  as  the  blood 
is  again  driven  into  it  by  successive  beats  of  the  heart. 
This  refilling  of  the  sac,  "  per  saltum,"  felt  by  the  hand 
placed  upon  the  tumour,  is  exceedingly  characteristic. 

The  mere  presence  of  the  aneurismal  tumour  may 
lead  to  a  feeling  of  weight  and  oppression,  as  in 
the  case  of  some  large  thoracic  aneurisms.  A  feeling  of 
stiffness  in  the  knee-joint  may  be  the  first  sign  of  a 
popliteal  aneurism.  Any  aneurism  occupying  the  flexure 
of  a  joint  tends  by  its  bulk  to  limit  the  movements  of 
that  joint.  Most  aneurisms  of  the  limbs  are  situated  in 
the  flexures  of  joints. 

Dulness  on  percussion,  of  little  value  in  the 
diagnosis  of  aneurisms  of  the  limbs,  becomes  of  much 
importance  in  connection  with  the  diagnosis  of  those 
which  are  in  the  neighbourhood  of  air  containing  viscera. 
Thus,  a  patch  of  dulness  over  the  upper  part  of  the 
sternum,  or  at  the  back  of  the  thorax,  may  be  an 
important  sign  of  aneurism. 

The  other  signs  and  symptoms  of  an  aneurism  are 
those  which  are  produced  by  the  pressure  of  the 
aneurismal  tumour  upon  surrounding  parts. 

In  the  case  of  aneurisms  of  the  limbs,  pressure  may 
be  exerted  upon  the  main  artery,  causing  weakness 
of  the  pulse  below. 


2  8o  SUKGICAL    DIAGNOSIS. 

Inequality  of  the  radial  pulses  is  a  common 
accompaniment  of  an  aneurism  of  the  arch  of  the  aorta, 
causing  pressure  upon  the  innominate  or  subclavian 
artery. 

Pressure  upon  nerves  may  cause  pain  down  the 
leg  in  a  case  of  popliteal  aneurism.  Similar  pain  down 
the  arm  or  along  the  course  of  an  intercostal  nerve  is 
often  produced  by  aortic  aneurism. 

Paralysis  of  the  left  recurrent  laryngeal  nerve  or  of 
the  sympathetic  nerve,  as  shown  by  the  paralysed  con- 
dition of  the  vocal  cord  and  the  contraction  of  the  pupil 
and  of  the  palpebral  fissure,  are  well-known  signs  of 
intrathoracic  aneurism.  Pressure  upon  neighbouring 
veins  and.  lymphatics  is  also  not  uncommon,  and 
may  lead  to  congestion  and  oedema  of  the  parts  below. 
Pressure  upon  the  oesophagus,  trachea,  bronchi, 
or  even  upon  the  lung  itself,  often  produces  character- 
istic symptoms  which  may  be  of  much  service  in  the 
diagnosis  of  intrathoracic  aneurism. 

Intracranial  aneurisms  may  sometimes  be  diagnosed, 
or  at  least  suspected,  if  careful  attention  be  paid  to  the 
cerebral  symptoms  produced  by  their  pressure.  Aneu- 
risms at  the  back  of  the  orbit  are  more  easily  diagnosed, 
since  their  pulsation  can  be  detected,  and  their  pressure 
effects  upon  the  eye  and  cellular  tissue  of  the  orbit  and 
eyelids  are  often  easily  recognisable. 


PART   III. 
INJUEIES. 

\  *  CHAPTER  XXVIII. 

EXAMINATION  AND  DIAGNOSIS  OF 
INJURIES  IN  GENERAL. 

The  diagnosis  of  a  case  of  recent  injury  depends  usually 
upon  the  application  of  common  sense  to  anatomical 
knowledge. 

When  called  to  a  case  of  injury  the  surgeon  should 
first  seek  to  ascertain  what  part  or  parts  of  the  body 
have  been  damaged.  This  he  may  do  by  questioning 
the  patient  himself,  or  by  questioning  bystanders  who 
may  have  witnessed  the  infliction  of  the  injury. 

He  must  further  ascertain  in  many  cases  whether  the 
clothes  show  any  evidence  of  the  exact  cause  of  the 
injury.  Thus  the  muddy  marks  of  a  cartwheel  upon  a 
coat  or  the  perforations  of  a  garment  by  a  bullet  may 
afford  valuable  evidence  as  to  the  precise  situation  of 
an  abdominal  contusion,  or  the  probable  track  of  a 
bullet  respectively. 

He  will  do  well  also  to  find  out  what  was  the  immediate 
result  of  the  accident,  whether  the  patient's  symptoms 


282  SURGICAL    DIAGNOSIS. 

came  on  at  once  or  gradually,  and  what  these  symptoms 
were. 

Next,  he  must  examine  carefully  the  person  of  the 
injured  patient,  and  must  remember  that  the  mere 
examination  of  an  injured  part  may  inflict  further 
damage  unless  care  be  taken  to  avoid  doing  so. 

Thus  rough  examination  of  a  fracture  may  result  in 
making  it  compound ;  injudicious  probing  of  a  wound 
may  start  serious  haemorrhage,  or  set  up  sepsis ;  and  so 
on. 

If  there  is  an  external  wound  the  surgeon  should  ask 
himself  what  structures  are  likely  to  have  been  involved, 
and  examine  to  see  whether  there  is  any  evidence  of 
their  having  been  injured.  Especially  important  is  it 
to  ascertain  whether  any  internal  cavities  have  been 
involved,  or  if  any  important  structures,  such  as  viscera, 
main  arteries,  or  nerves  have  been  wounded  or  not. 

He  must  remember  that  more  than  one  injury  may 
have  been  produced  at  the  same  time,  and  must  there- 
fore be  on  his  guard  against  assuming  that  the  first 
injury  that  he  discovers  is  the  sole  or  even  the  most 
important  lesion. 


CHAPTER  XXIX. 
INJURIES  TO  THE  HEAD. 

I.  Injuries  to  the  soft  parts  outside  the  skull 

usually  present  but  little  difficulty  in  diagnosis. 

A  few  points  only  need  be  mentioned. 

Contusions  of  the  scalp  in  some  cases  simulate  a 
depressed  fracture  of  the  skull,  the  centre  of  the  con- 
tusion being  soft,  while  the  periphery  presents  to  the 
examining  finger  a  harder  ring  or  edge,  which  by  the 
unwary  may  be  taken  for  an  edge  of  fractured  bone. 

Apart  from  the  special  signs  and  symptoms  usually 
presented  by  a  depressed  fracture,  the  diagnosis  between 
the  two  conditions  may  usually  be  made  in  the  following 
manner.  If  the  forefinger  be  placed  on  the  centre  of 
the  swelling  it  will  generally  be  found  possible,  in  the 
case  of  a  mere  contusion,  to  feel  firm  resisting  under- 
lying bone  when  the  finger  has  been  depressed 
sufficiently  firmly  and  deeply.  If,  however,  the  finger 
can  be  depressed  below  the  level  of  the  surrounding 
bone,  then  there  must  be  a  depression  of  the  bone — 
that  is,  a  fracture. 

In  the  case  of  wounds  about  the  face,  care  should  be 
taken  to  notice  whether  any  cavity  has  been  opened, 
and  whether  the  wound  involves  the  facial  nerve  or 
Steno's  duct. 


284  SURGICAL    DIAGNOSIS. 

II.  Injuries  to  the  soft  parts  inside  the 
skull. 

In  every  case  of  injury  to  the  head,  even  when 
apparently  trivial,  attention  should  be  directed  to  the 
state  of  the  soft  parts  inside  the  skull,  that  is,  the 
brain.  The  brain  may  be  damaged  with  or  without 
fracture  of  the  skull,  but  in  either  case  there  may  exist 
symptoms  pointing  directly  to  a  cerebral  lesion. 

Practically,  as  the  result  of  an  injury  to  the  brain, 
there  may  ensue  one  or  other  of  three  states  :  (a) 
Concussion  ;  (h)  Compression ;  (c)  Irritation.  Each  of 
these  has  its  own  group  of  symptoms,  although  not 
infrequently  those  of  two  or  more  may  be  combined. 

{cb)  In  concussion  the  most  marked  feature  is 
insensibility  coming  on  instantaneously,  at  the  time  of 
the  injury.  The  patient's  face  is  pale,  his  pulse  is 
feeble,  and  his  respiration  shallow,  his  temperature 
probably  subnormal. 

(&)  In  compression,  whether  from  depression  of  a 
fractured  piece  of  bone,  or  from  haemorrhage,  or,  later, 
from  the  accumulation  of  inflammator}^  products,  there 
is  a  different  group  of  symptoms. 

There  is  insensibility,  but  this  does  not  necessarily 
come  on  at  the  time  of  the  accident.  If  due  to  the 
gradual  accumulation  of  blood  or  other  fluid,  it  comes 
on  gradually  or  gradually  deepens. 

The  face  is  often  congested,  the  breathing  is  usually 
slow,  heavy,  and  stertorous,  owing  to  the  paralysis  of 
the  soft  palate  and  other  muscles.  The  pulse  is  probably 
full  and  bounding,  and  has  a  tendency  to  be  slow.  There 
is  often  paralysis  of  one  or  more  limbs  or  groups  of 
muscles.     The  sphincters  tend  to  be  relaxed. 

In  most  cases  the  insensibility  produced  by  concussion 


INJURIES    TO    THE    HEAD.  285 

has  not  passed  off  before  that  due  to  compression  sets 
in,  and  it  is  sometimes  very  difficult  to  say  how  far  the 
insensibility  is  due  to  the  one  or  the  other  condition. 
In  some  cases  of  compression  due  to  haemorrhage,  there 
is  a  characteristic  interval  of  consciousness  or  partial 
consciousness  intervening  between  the  time  of  the 
accident  and  the  supervention  of  the  symptoms  of 
compression. 

(c)  Cerebral  irritation  is  shown  by  a  tendency  to 
restlessness  and  to  spasmodic  movements  of  various 
muscles.  It  is  most  often  due  to  laceration  of  the  sur- 
face of  the  brain,  and  the  signs  and  symptoms  are  most 
characteristic  when  the  lesion  affects  the  motor  area 
of  the  cerebral  convolutions.  In  such  cases  spasmodic 
movements  may  be  seen  in  the  limb  or  group  of  muscles 
whose  cortical  centre  is  situated  at  the  injured  spot. 

III.  Injury  to  the  bones  of  the  cranium. 

Fracture  of  the  skull  is  diagnosed  partly  by  direct 
examination  of  the  broken  bone,  partly  by  inference 
from  the  concomitant  damage  that  has  been  inflicted 
upon  the  brain  and  other  soft  parts  within  the  skull, 
and  upon  the  cranial  nerves  passing  through  the  bone. 
In  some  cases  (especially  in  fractures  of  the  base) 
important  evidence  is  derived  from  the  escape  of  the 
fluid  contents  of  the  skull. 

As  a  rule  it  may  be  stated  that  fractures  of  the  vault 
of  the  skull  are  usually  diagnosed  by  direct  examination 
of  the  broken  bone.  In  fracture  of  the  base,  on  the 
other  hand,  the  diagnosis  is  made  almost  entirely  by 
inference  and  by  the  evidence  derived  from  the  brain 
or  cranial  nerves,  or  from  the  escape  of  fluids  from  the 
interior  of  the  skull. 

Fractures  of  the  vault  of  the  skull,  which  are  more 


2  86  SURGICAL    DIAGNOSIS. 

or  less  accessible  to  direct  examination,  are  usually 
diagnosed  by  sight  and  touch.  A  depression  can  be 
felt,  an  edge  or  ridge  of  bone  is  palpable,  a  fissure  can 
be  seen  or  felt.  In  compound  fractures  the  examina- 
tion of  the  bone  is  most  easily  made. 

In  every  case  of  supposed  injury  to  the  bones  of  the 
skull  a  full  and  careful  examination  of  the  whole  vault 
should  be  made.  If  there  is  a  wound  this  should  also 
be  most  carefully  examined  with  both  finger  and  probe. 
Care  must  of  course  be  taken  that  both  are  thoroughly 
clean  before  they  are  inserted  into  the  wound.  A  crack 
in  the  bone  is  best  detected  with  a  probe  or  finger  nail ; 
a  depression  with  the  pulp  of  the  finger. 

Natural  sutures  may  be  mistaken  for  fissured  frac- 
tures. Natural  slight  irregularities  in  the  surface  of 
some  skulls  may  occasionally  be  somewhat  difficult  to 
diagnose  from  traumatic  depressions. 

Occasionally  a  line  of  subcutaneous  hgemorrhage 
across  the  forehead,  or  a  collection  of  blood  under  the 
hairy  scalp,  ma}'  be  a  valuable  sign  of  fissured  fracture. 
But  care  must  be  taken  in  such  cases  to  be  sure  that 
the  blood  extravasation  is  not  due  merely  to  injury  to 
the  soft  parts  outside  the  skull. 

Fracture  of  the  base  of  the  skull  is  diagnosed  by 
one  or  more  of  three  groups  of  symptoms. 

(a)  The  symptoms  of  severe  injury  to  the 
brain. — Thus,  a  patient  who  has  been  concussed,  and 
who  remains  unconscious  for  many  days,  is  almost  certain 
to  have  sustained  a  fracture  of  some  part  of  the  base  of 
the  skull,  even  though  no  definite  signs  of  fracture  have 
manifested  themselves.  Rapidly  deepening  compres- 
sion, indicating  intracranial  haemorrhage,  is  also  in  itself 
strongly  suggestive  of  fracture. 


INJURIES   TO   THE   HEAD.  287 

(b)  The  escape  of  blood,  or  cerebro -spinal 
fluid  (and  very  rarely  of  brain  substance)  through  the 
fracture. 

Every  fracture  causes  a  certain  amount  of  haemorrhage 
from  the  vessels  in  the  bone,  or  from  those  lying  in  close 
contact  with  it.  This  bleeding  may  take  place  on  the 
inner  surface  of  the  fractured  bone,  in  which  case  symp- 
toms of  intracranial  pressure  or  irritation  will  ensue. 

Or,  the  blood  may  pass  outwards  and  collect  under 
the  soft  tissues  which  cover  the  bone.  Thus,  a  fracture 
of  the  posterior  fossa  often  leads  to  the  formation  of  a 
deeply-seated  haematoma  behind  the  ear  and  at  the  upper 
part  of  the  neck.  If  it  is  quite  clear  that  such  a  hge- 
matoma  is  not  due  to  a  direct  blow  upon  these  soft  parts, 
then  it  becomes  a  most  important  sign  of  fracture  of 
the  posterior  fossa. 

Similarly,  blood  extravasated  from  a  fracture  at  the 
anterior  part  of  the  base  of  the  skull  makes  its  way  into 
one  or  both  orbits,  and  causes  the  well-known  discolora- 
tion of  the  eyelids  and  subconjunctival  tissues. 

Or,  the  blood  may  pass  to  the  surface  of  the  body  and 
become  visible  externally. 

This  occurs  when  the  fracture  traverses  a  cavity  such 
as  the  middle  ear,  and  is  attended  by  rupture  of  the  soft 
parts  covering  the  bone  (e.g.,  the  membrana  tympani). 

As  a  very  large  number  of  fractures  of  the  base  of 
the  skull  do  involve  the  petrous  bone  and  so  the  middle 
ear,  bleeding  from  the  ear  becomes  a  very  important 
sign  of  fracture  of  the  base. 

Before  accepting  bleeding  from  the  ear  as  a  sign  of 
fractured  base,  it  must  be  ascertained  that  the  blood  has 
not  merely  run  into  the  ear  as  the  result  of  some  com- 
paratively trivial  wound  of  the  external  ear  or  meatus. 


2  88  SURGICAL   DIAGNOSIS. 

It  is  also  possible  for  a  rupture  of  the  membrana  tym- 
pani  to  cause  a  minute  haemorrhage,  and  a  pre-existing 
polypus  or  other  disease  of  the  ear  may  do  the  same 
thing. 

Bleeding  from  the  nose  is  also  a  common  sign  of  frac- 
ture of  the  anterior  part  of  the  base.  But  bleeding 
from  the  nose  is  so  common  as  the  result  of  direct  blow 
upon  the  organ  that  much  caution  has  to  be  exercised 
before  it  can  be  accepted  as  a  positive  sign  of  fracture  of 
the  anterior  fossa. 

Sometimes  the  blood  from  a  fracture  of  the  anterior 
part  of  the  base  makes  its  way  into  the  pharynx  and 
thence  to  the  stomach,  revealing  its  presence  only  when 
vomiting  sets  in. 

Cerebro-spinal  fluid  may  escape  through  a  fracture 
whenever  there  has  also  been  a  rent  in  the  dura  mater. 
When  cerebro-spinal  fluid  escapes  into  the  tissues  it  is 
rarely  of  much  importance  as  a  diagnostic  sign,  because 
it  is  not  easily  recognised  as  such.  But  when  it  escapes 
on  to  the  surface  through  the  ear  it  affords  a  sign  of 
the  utmost  value.  A  discharge  of  a  quantity  of  clear 
watery  fluid  from  the  ear,  coming  on  shortly  after  an 
injury  to  the  head  and  persisting  for  many  hours  or 
days,  is  pathognomonic  of  fracture  of  the  base  involving 
the  petrous  bone. 

It  can  be  confused  with  nothing  else,  since  the  fluid 
from  the  middle  ear  is  too  small  in  quantity,  and  the 
fluid  from  a  chronic  catarrh  of  the  ear  is  too  viscid  and 
turbid,  to  permit  of  their  being  mistaken  for  the  clear, 
watery,  cerebro-spinal  fluid  which  runs  away  in  con- 
siderable quantity. 

(c)  Symptoms  caused  by  injury  to  cranial 
nerves. — Since  these  nerves  pass  through  foramina  in 


INJURIES    TO    THE   HEAD.  289 

the  base  of  the  skull  it  is  not  unlikely  that  one  or  more 
of  them  will  be  damaged  by  fracture  of  the  bose. 
Especially  important  in  this  respect  is  the  facial 
nerve,  which,  on  account  of  its  long  course  within  the 
petrous  bone,  is  very  liable  to  be  paralysed  by  a  frac- 
ture traversing  that  bone. 

The  delicate  little  nerves  which  supply  the  muscles  of 
the  orbit  (3rd,  4th,  and  6th)  are  also  very  likely  to  be 
compressed  and  paralysed  by  the  pressure  of  extra- 
vasated  blood. 

The  hypoglossal  nerve,  too,  is  sometimes  damaged  in 
cases  of  fracture  of  the  posterior  fossa. 

The  other  cranial  nerves  are  seldom  involved  in 
fracture  of  the  base  in  such  a  manner  as  to  give  rise  to 
diagnostic  signs  of  importance. 


T 


CHAPTER  XXX. 

INJURIES  TO  THE  NECK. 

In  investigatiDg  a  case  of  injury  to  the  neck  (excluding 
the  cervical  spine,  which  is  dealt  with  in  the  chapter 
on  injuries  of  the  spine)  the  chief  points  to  which 
attention  should  be  directed  are  : 

1.  Whether  the  main  vessels  or  nerves  have  been 

injured. 

2.  Whether  any  mucous  cavity  (pharynx,  oesophagus, 

larynx,  or  trachea)  has  been  ojoened. 

3.  Whether  the  cellular  tissue  at  the  deeper  parts  of 

the  neck  has  been  opened  up,  and,  if  so,  whether 

it  has  become  infected,  either  from  without,  or 

from  within,  from  one  of  the  mucous  cavities. 

I.  Injury  to  main  vessels  and  nerves  rarely  occurs 

except  in  cases  of  external  wound  (cut  throat),  and  in 

such  cases  the  diagnosis  of  the  parts  wounded  depends 

upon  the  position,  depth,  extent,  and  direction  of  the 

wound  as  regards  the  various  anatomical  structures  in 

the  neck.     The  examination  of    the    pulsation  in  the 

artery  beyond  the  wounded  part  and  of    the  muscles 

supplied  by  the  nerves,  may  afford  some  help  in  the 

diagnosis  of  a  wound  of  these  parts. 

With  regard  to  arterial  haemorrhage,  it  is  well  to 
remember  that,  except  in  cases  that  are  very  rapidly 


INJURIES    TO    THE    NECK.  29 1 

fatal,  severe  haemorrhage  seldom  comes  from  the  main 
carotid  arteries,  but  rather  from  the  numerous  branches 
of  the  external  carotid. 

2.  The  opening  of  a  mucous  cavity  is  serious  because 
it  is  likely  to  cause  infection  of  the  cellular  tissue  in 
the  neighbourhood  of  that  cavity.  If  the  cavity  be  the 
larynx  or  trachea,  air  is  likely  to  be  forced  out  into  the 
tissues,  and  surgical  emphysema  thus  be  produced. 

Especially  dangerous  on  this  account  is  a  rupture  of 
the  trachea  without  external  wound.  Dangerous  for 
the  same  reason  are  wounds  of  the  air  passages  with 
very  small  external  wounds. 

Injuries  to  the  larynx,  whether  wounds  or  contusions, 
are  dangerous  on  account  of  their  liability  to  cause 
serious  narrowing  of  this  already  narrow  part  of  the 
respiratory  tract.  Such  narrowing  may  be  due  to 
inflammatory  oedema,  to  submucous  hgemorrhage,  or  to 
actual  blocking  of  the  rima  glottidis  by  means  of  a 
detached  or  partially  detached  piece  of  mucous  mem- 
brane, cartilage,  or  other  portion  of  the  larynx. 

In  any  case  then  of  injury  to  the  neck  some  attention 
should  be  directed  to  the  breathing,  and  it  should  not 
be  forgotten  that  after  an  injury  to  the  larynx  severe 
or  even  fatal  difficulty  in  breathing  may  set  in  very 
rapidly  from  any  of  the  above-mentioned  causes. 

3.  The  danger  of  a  septic  inflammation  of  the 
cellular  tissue  at  the  root  of  the  neck  is  well  known. 
Upon  the  diagnosis  of  the  septic  or  non-septic  nature 
of  the  wound  must  necessarily  depend  very  largely  the 
question  of  treatment.  If  there  is  any  serious  doubt 
about  the  matter  it  is  best  to  treat  the  wound  as  a 
septic  one,  by  keeping  it  as  open  as  possible.  Thus  are 
best     avoided  the    serious   and    often  very    insidious 


292  SURGICAL   DIAGNOSIS. 

complications  due  to  the  spread  of  septic  inflammation 
to  the  mediastinum,  pleura  or  pericardium. 

Injuries  of  the  hyoid  bone  and  larynx  are 
to  be  diagnosed  by  the  history,  by  local  tenderness,  and 
perhaps  signs  of  bruising,  by  the  loss  of  normal  resist- 
ance or  palpation  if  fracture  have  occurred,  and  by  the 
hoarseness  and  dyspnoea  which  will  probably  be  present. 
Laryngoscopic  examination  will  show  bruising  or 
inflammatory  swelling.  It  must  be  borne  in  mind  that 
injury  to  these  parts  may  cause  very  rapid  swelling  of 
the  submucous  tissues  about  the  larynx  (from  ecchymosis 
or  inflammation),  and  that  this  may  easily  lead  to  sufib- 
cation  if  the  surgeon  be  not  ready  promptly  to  perform 
tracheotomy  or  intubation. 


CHAPTER  XXXI. 

INJURIES  TO  THE  CHEST, 

In  examining  any  case  of  injury  to  the  chest  the  first 
point  to  be  ascertained  is  whether  the  injury  is  one 
which  is  confined  wholly  to  the  chest  wall,  or  whether 
the  thoracic  viscera  are  also  implicated.  The  serious- 
ness of  an  injury  to  the  chest  depends  almost  entirely 
upon  the  extent  to  which  the  viscera  have  been 
damaged. 

Injuries  limited  to  the  Chest  Wall. 

Fractures  of  ribs  are  detected  by  placing  the  hand 
flat  upon  various  parts  of  the  chest  and  directing 
the  patient  to  draw  a  deep  breath  ;  the  movement  of 
the  broken  ends  upon  each  other  may  cause  a  sudden 
sharp  pain  ;  or  a  click  may  be  felt  or  heard  by  the 
patient  or  by  the  examining  surgeon.  Gentle  pressure 
with  one  finger  at  various  points  along  the  course  of 
each  rib  may  reveal  a  diminution  of  the  normal  elasticity 
and  resistance  of  the  rib,  thus  indicating  fracture.  Or 
crepitus  may  be  thus  elicited.  Or  irregularity  of  the 
bone  may  be  detected  by  drawing  the  finger  gently 
along  the  course  of  each  rib  in  succession. 

Fracture  of  a  rib  is  most  likely  to  be  overlooked  when 


2  94  SURGICAL    DIAGNOSIS. 

it  occurs  far  back  near  the  angle,  where  the  bone  is 
more  covered  with  muscle,  scapula,  or  other  superficial 
structures. 

Care  must  be  taken  that  the  ends  of  the  broken  rib  be 
not  pressed  backward  into  the  lung,  causing  further 
damage  to  that  organ. 

The  use  of  X-rays  in  the  detection  of  fractures  of  rib 
is  obvious. 

Fracture  of  the  sternum  is  usually  easily  detected 
by  the  history  of  injury  to  that  part,  by  the  irregularity 
of  the  fractured  bone,  and  by  the  diminished  resistance 
to  pressure  exerted  upon  it  by  a  finger. 

Wounds  limited  to  the  chest  wall  are  of  importance 
only  if  a  large  artery,  such  as  an  intercostal  or  a  branch 
of  the  axillary,  has  been  wounded,  or  if  the  wound  be 
septic.  An  incised  or  punctured  wound  of  an  inter- 
costal artery  occurs,  however,  but  very  rarely  without 
wound  of  the  pleura  as  well.  In  the  latter  case  the 
bleeding  will  probably  take  place  into  the  cavity 
of  the  thorax,  and  care  must  be  taken  not  to  over- 
look it. 

Injuries  involving  Thoracic  Contents. 

In  investigating  the  nature  and  extent  of  a  supposed 
injury  to  the  contents  of  the  thorax,  the  diagnosis  has 
to  be  made  mainly  by  careful  physical  examination. 
The  examination  must  be  made  by  inspection,  palpation, 
percussion,  and  auscultation.  Just  as  much  care  and 
skill  are  required  in  the  examination  of  an  injured 
thorax  by  a  surgeon  as  in  the  examination  of  a 
diseased  chest  by  a  physician.  The  surgeon,  however, 
who  is  usually  less  well  versed  in  the  arts  of  medicine, 


INJURIES    TO    THE    CHEST.  295 

will  often  do  well  to  avail  himself,  if  it  be  possible,  of 
the  help  of  a  physician  in  such  cases. 

It  should  not  be  forgotten  that  the  injured  chest 
may  also  be  a  diseased  chest,  and  the  signs  and  symp- 
toms of  injury  may  be  much  complicated  by  those  of 
the  pre-existing  disease. 

A  little  attention  to  the  earlier  history  of  the  case 
will  usually  prevent  any  mistake  in  this  direction. 

The  general  appearance  of  the  patient  may  afford 
some  help  in  the  diagnosis  of  a  severe  internal  injury. 

Thus  a  wound  of  the  heart  or  pericardium  almost 
aLvays  produces  considerable,  although  perhaps  only 
transient,  collapse.  Any  injury  which  suddenly  prevents 
a  lung  from  performing  its  proper  function  produces 
more  or  less  dyspnoea. 

The  difficulty  in  breathing  produced  by  injury  to  the 
lung  must  be  distinguished  from  that  due  to  injury 
to  the  thoracic  wall.  In  the  latter  case  the  breathing 
may  be  difficult  simply  because  it  is  painful.  In  the 
case  of  a  severe  injury  to  the  lung  itself  there  is  diffi- 
culty in  filling  the  lungs  properly  with  air.  The 
breathing  tends  to  be  quickened,  and  cyanosis  is  likely 
to  be  present  as  well. 

Inspection. — Any  external  mark  of  injury,  such  as 
a  bruise  or  a  wound,  may  afford  some  indication  as  to 
the  seat  of  the  injury. 

In  most  cases,  however,  the  external  marks  of  injury 
are  of  but  little  help  in  the  diagnosis  of  an  internal 
injury.  A  most  severe  or  even  fatal  injury  to  the 
lungs,  heart,  or  great  vessels  may  occur  without  any 
sign  of  external  injury.  Such  injuries  may  even  occur 
in  cases  of  crush,  without  any  fracture  of  the  ribs  ; 
but    only    in    young    children,  in    whom    the    thoracic 


296  SURGICAL    DIAGNOSIS. 

wall  is  soft  and  yielding.  A  large  external  wound 
may  indicate  at  once  that  the  viscera  have  been 
wounded.  The  viscera  may  be  actually  exposed,  or 
air  may  be  seen  to  pass  in  and  out  of  the  wound 
with  each  act  of  respiration. 

Such  cases  present  less  difficulty  in  diagnosis  than 
those  in  which  the  external  injury  is  very  small  or  even 
apparently  trivial.  Punctured  wounds,  such  as  those 
from  a  needle  or  a  penknife,  may  present  a  hardly 
noticeable  external  wound,  and  yet  may  be  connected 
with  a  most  serious  wound  of  the  heart. 

Inquiry  as  to  the  direction  and  depth  of  the  wound, 
and  the  nature  of  the  instrument  with  which  it  was 
made,  may  afford  help  in  the  diagnosis. 

Impaired  movement  of  the  chest  wall  may  be 
due  merely  to  the  pain  produced  by  a  bruise  or  by  a 
broken  rib,  but  is  more  often  indicative  of  a  visceral 
lesion. 

A  bulging  of  the  chest  wall  on  one  side  may  indicate 
ftn  extreme  degree  of  pneumothorax. 

Palpation. — A  subcutaneous  crackling  (surgical 
emphysema)  indicates  a  wound  of  the  lung  in  all  cases 
except  those  very  rare  ones  in  which  air  has  entered  the 
subcutaneous  tissue  through  an  external  wound.  In  the 
latter  case  the  emphysema  is  never  more  than  slight  and 
limited  to  the  immediate  neighbourhood  of  the  wound. 

The  loss  of  resistance  in  the  chest  wall  due  to 
fractured  ribs  is  easily  detected  by  palpation. 

A  shifting  of  the  position  of  the  heart  due  to  the 
collapse  of  a  lung  or  to  great  distension  of  the  pleura 
with  air,  as  in  some  cases  of  pneumothorax,  may  be 
detected  by  palpation  of  the  apex  beat,  but  is  better 
indicated  by  percussion  of  the  area  of  cardiac  dulness. 


INJURIES    TO    THE    CHEST.  297 

Percussion  is  of  great  value  in  the  diagnosis  of 
injury  to  tbe  thoracic  viscera.  The  shifting  of  the  area 
of  cardiac  dulness  to  one  or  other  side  in  cases  of 
collapse  of  one  lung  and  pneumothorax  has  already  been 
mentioned.  Extension  of  the  area  of  cardiac  dulness 
occurs  in  wound  of  the  heart  or  great  vessels  within 
the  pericardium,  and  is  due  to  the  accumulation  of 
blood  within  that  cavity.  Taken  together  with  feeble- 
ness of  pulse  and  inability  to  hear  the  heart  sounds 
properly,  it  is  a  very  valuable  sign  of  wound  of  the  heart. 

But  if  the  pericardium  has  been  freely  opened  into 
the  pleura  the  blood  will  escape  into  that  cavity,  and 
the  pericardium  does  not  become  distended. 

Of  the  value  of  percussion  in  the  detection  of 
fluid  (blood)  in  the  pleural  cavity,  but  little  need  be 
said.  The  signs  of  fluid  in  the  pleura  are  too  well 
known  to  need  repetition  here.  Air  iu  the  pleura 
(pneumothorax)  gives  a  hyper-resonant  note,  and  is 
usually  accompanied  by  some  displacement  of  the 
heart,  especially  if  the  air  accumulate  under  pres- 
sure. 

A  pneumothorax  is  closely  simulated  by  a  diaphrag- 
matic hernia  through  a  rent  in  the  diaphragm.  Such 
an  injury  to  the  diaphragm  is  usually  accompanied 
by  fracture  of  many  of  the  lower  ribs.  The  physical 
signs  produced  by  the  presence  of  the  distended 
stomach  and  colon  within  the  pleural  cavity  are  almost 
identical  with  those  of  pneumothorax.  The  distin- 
guishing feature  is  the  hollowness  of  the  abdomen, 
which  in  a  case  of  diaphragmatic  hernia  has  thus  lost 
some  of  its  contents. 

Auscultation  of  the  thorax  in  cases  of  injury  may 
be  useful  in  the  detection  of  friction  in  the  pleura  or 


298  SURGICAL   DIAGNOSIS. 

pericardium,  caused  by  the  presence  of  blood  or,  later, 
by  inflammatory  roughening  of  the  serous  membrane. 

It  may  be  useful  in  detecting  the  presence  of  blood 
within  the  lung  in  cases  of  local  laceration  or  bruising ; 
the  blood  causes  a  rale. 

Auscultation  is  of  most  use,  however,  in  showing 
that  the  normal  respiratory  murmur  is  absent  from 
certain  parts.  This  may  be  due  to  the  presence  of 
blood  in  the  pleura  or,  later,  of  serous  effusion. 

An  alteration  in  the  normal  vesicular  murmur  may 
indicate  solidification  of  the  lung  from  bruising  or  from 
inflammatory  consolidation.  Finally,  pneumothorax 
causes  absence  of  normal  breath  sounds  over  the 
affected  portion  of  the  pleura,  and  of  more  importance 
still  are  the  metallic  tinkling,  amphoric  and  splashing 
sounds  which  are  met  with  in  large  cavities  containing 
air  or  air  and  fluid  together. 

In  conclusion,  a  few  words  may  be  said  about 
hsemoptysis  as  a  sign  of  injury  to  the  lung. 

Hemoptysis  is  a  common  sign  of  injury  to  the  lung, 
but  it  is  by  no  means  necessarily  present  in  every  case. 
It  may  occur  in  cases  of  slight  bruising  of  the  lung,  such 
as  often  occurs  in  connection  with  fracture  of  the  ribs. 
It  does  not  necessarily  mean  penetration  of  the  lung  by 
the  broken  rib. 

Haemoptysis  is  not  necessarily  present  even  in  the 
most  severe  cases  of  injury  to  the  lung.  In  cases  of 
extensive  crush  of  the  root  of  the  lung  haemoptysis 
may  be  conspicuous  by  its  absence.  In  children 
especially,  haemoptysis  is  less  common  as  the  result  of 
injury  to  the  lungs  than  it  is  in  adults. 

In  incised  wounds  of  the  lungs,  as  might  be  expected, 
haemoptysis  is  usually  a  prominent  feature. 


CHAPTER  XXXIL 

INJURIES  TO  THE  ABDOMEN. 

When  a  surgeon  is  called  upon  to  investigate  a  case  of 
injury  to  the  abdomen  his  first  thought  should  be  of 
the  viscera.  He  should  endeavour  by  all  means  in  his 
power  to  ascertain  whether  any  of  them  have  been 
damaged,  and  if  so,  which  of  them,  and  to  what  extent, 
and  in  what  manner. 

He  must  bear  in  mind  too  that  more  than  one  organ 
may  have  been  damaged.  He  will  also  do  well  not  to 
forget  to  inquire  into  the  previous  history  of  the 
various  viscera,  and  to  ask  himself  whether  any  of  the 
symptoms  that  are  present  may  not  be  due  to  pre- 
existing disease.  Sometimes  when  the  symptoms  are 
more  severe  than  the  trivial  nature  of  the  injury  seems 
to  warrant,  he  will  be  wise  to  consider  whether  they 
are  not  due  to  the  lighting  up  of  some  previous 
quiescent  disease  rather  than  to  the  injury  alone. 
Thus  a  very  slight  blow  upon  the  right  iliac  fossa  may 
start  an  acute  attack  of  appendicitis.  A  tap  upon  an 
enlarged  malarious  spleen  may  cause  very  severe 
internal  haemorrhage.  A  blow  upon  a  chronic  intra- 
peritoneal abscess  or  cyst  may  lead  to  its  rupture,  and 
so  on. 

Injuries  confined  to  the  abdominal  wall  are  rarety 


300  SUEGICAL    DIAGNOSIS. 

serious,  and  their  consideration  need  not  detain  us  long. 
The  abdominal  wall  may  be  contused  or  wounded. 
In  the  latter  case  it  is  possible  that  an  artery  of  con- 
siderable size,  such  as  the  epigastric  or  internal 
mammary,  may  have  been  wounded.  The  situation  of 
the  wound  and  the  amount  of  haemorrhage,  either 
external  or  into  the  muscular  layers,  will  generally 
indicate  the  nature  of  the  lesion. 

In  a  doubtful  case  it  may  be  desirable  to  open  up 
the  wound,  and  thus  to  ascertain  more  fully  the  exact 
extent  and  nature  of  the  injury.  Wounds  limited  to 
the  abdominal  wall  do  not  produce  any  marked  effect 
upon  the  general  aspect  of  the  patient  or  upon  his 
pulse. 

A  wound  of  the  abdominal  wall  may  open  the 
peritoneal  cavity  and  yet  not  inflict  any  damage  upon 
the  abdominal  viscera.  The  wound  may  be  sufficiently 
large  to  show  at  once  that  this  cavity  has  been  opened. 
Or  examination  with  a  finger  or  probe  may  show  clearly 
that  such  is  the  case.  In  most  cases  of  punctured 
wound  there  is,  however,  at  first  no  definite  evidence 
whether  the  peritoneal  cavity  has  been  opened  or  not. 
In  such  a  case  it  is  usually  advisable  to  enlarge  the 
wound,  and  ascertain  definitely  as  soon  as  possible 
whether  any  visceral  lesion  has  occurred.  If  there  is 
definite  evidence  that  the  peritoneal  cavity  has  been 
opened,  such  as  that  afforded  by  the  escape  of  peri- 
toneal fluid  or  of  omentum,  then  such  an  exploratory 
operation  is  all  the  more  needful. 

Cases  in  which  there  is  an  external  wound,  present 
as  a  rule,  less  difficulty  in  diagnosis  than  those  in 
which  there  is  no  such  wound,  and  we  may  therefore 
pass  at  once  to  the  consideration  of  those  more  common 


INJURIES    TO    THE    ABDOMEN.  301 

and  more  difficult  cases  in  which  the  abdomen  has 
received  an  injury  which  has  not  caused  any  external 
wound. 

In  the  great  majority  of  cases  of  injury  to  the 
abdominal  viscera,  the  injury  has  been  caused  by  a 
direct  blow  upon  the  abdomen  or  by  the  abdomen 
having  been  squeezed^  as  by  the  passage  of  a  wheel 
across  it.  In  a  small  minority  of  cases  a  viscus  has 
been  ruptured  or  displaced  by  a  fall  without  a  direct 
blow  having  been  inflicted  on  the  exterior  of  the 
abdomen.  Such  are  certain  rare  cases  of  laceration  or 
displacement  of  large  solid  organs,  notably  the  liver 
and  spleen. 

Evidence  as  to  the  existence  of  an  injury  to  an  abdo- 
minal viscus  is  obtained  in  the  following"  manner  : 


'to 


I.   Evidence  from   the   History   of  the 
Accident. 

The  patient,  or  those  who  may  have  witnessed  the 
accident,  should  be  carefully  questioned  as  to  the  exact 
manner  in  which  the  injury  was  inflicted,  the  position 
in  which  the  patient  was  at  the  moment  of  the  acci- 
dent, and,  if  possible,  the  exact  part  of  the  abdomen 
upon  which  the  injury  was  inflicted. 

2.  Examination  of  the  Patient's  Clothing 
and  of  the  Surface  of  the  Abdomen. 

In  the  case  of  a  wheel  having  passed  across  the 
abdomen,  examination  of  the  clothing  may  indicate  by 
the  mud  stains  the  precise  point  across  which  the 
wheel  passed. 


30  2  SURGICAL    DIAGNOSIS. 

Examination  of  the  surface  of  the  abdomen  in  such 
a  case,  or  in  the  case  of  a  direct  blow  such  as  that 
inflicted  by  the  kick  of  a  horse  or  the  pole  of  a  waggon, 
may  afford  valuable  evidence  of  the  precise  situation  of 
the  injury  by  revealing  a  bruise  or  slight  laceration  of 
the  skin. 

It  must  be  carefulty  borne  in  mind,  however,  that 
the  most  severe  internal  injuries  may  have  been,  and 
as  a  matter  of  fact  often  are,  inflicted  without  leaving 
the  slightest  mark  upon  the  external  surface  of  the 
body. 

The  ahsence  of  external  marks  of  injury  does  not 
warrant  the  conclusion  that  the  viscera  have  escaped 
injury. 

3.  Examination  of  the  general  Condition 
of  the  Patient. 

In  many  cases  it  is  at  once  obvious  from  the  aspect 
of  the  patient's  face  that  he  has  sustained  a  severe 
internal  injury.  The  pinched,  drawn  aspect  of  the 
features  may  be  very  characteristic.  Collapse  is  an 
important,  but  by  no  means  necessary,  accompaniment 
of  a  severe  internal  injury.  Mere  pallor  of  the  face  and 
feebleness  of  the  pulse,  although  suggestive  of  a  serious 
lesion,  may  be  due  entirely  to  fright  caused  by  the 
accident. 

4.  Examination  of  the  Abdomen. 

External  marks  of  injury  have  already  been  men- 
tioned. 

Local  tenderness  is  important.  Superficial  ten- 
derness indicates  injurj-  to  the  abdominal  wall.     Deep- 


INJURIES    TO    THE    ABDOMEN.  303 

seated  tenderness  is  more  characteristic  of  an  internal 
injury. 

Fracture  of  the  lower  ribs  indicates  that  these  have 
probably  been  driven  inwards  and  backwards  towards 
the  spine,  and  are  suggestive  of  crush  of  the  liver  or 
spleen.  Similarly,  fracture  of  the  pelvis,  caused  by  the 
passage  of  a  wheel  across  this  part,  is  suggestive  of  an 
injurj^  to  the  intestines  lying  in  the  iliac  fossa,  or  to  the 
common  or  external  iliac  vessels. 

Rigidity  of  the  abdominal  muscles  is  a  very 
important  sign  of  injury  to  the  subjacent  viscera.  Seri- 
ous lesions  of  viscera  rarely  occur  without  this  sign  ; 
and  its  existence  together  with  local  pain  and  tender- 
ness are  usually  sufficient,  even  in  the  absence  of  other 
evidence,  to  warrant  an  exploratory  abdominal  section. 

Injury  inflicted  upon  the  centre  of  tbe  abdomen  is 
usually  more  serious  than  that  upon  tlie  upper  or 
lower  parts  ;  in  these  parts  the  underlying  viscera  are 
more  likely  to  have  been  protected  by  the  ribs  or 
pelvis. 

Injury  to  the  unprotected  part  of  the  abdomen  is 
likely  to  cause  crushing  of  the  intestine  by  jamming  it 
against  the  hard  and  projecting  lumbar  spine.  Those 
portions  of  the  intestine  which  are  least  able  to  slip 
freely  to  one  side  are  those  most  liable  to  injury.  Thus 
the  fixed  portion  of  the  duodenum  is  tlie  part  of  the 
intestine  that  is  most  liable  to  rupture.  Similarly  the 
lower  end  of  the  ileum,  with  its  very  short  mesentery, 
is  more  likely  to  be  torn  than  the  other  parts  of  the 
small  intestines,  whose  longer  mesentery  permits  greater 
freedom  of  movement. 

Severe  pain  at  or  near  the  seat  of  injury  is  very 
suggestive  of  irritation    of    the  peritoneum,  from   the 


304  SURGICAL    DIAGNOSIS. 

escape  of  the  acrid  contents  of  the  intestine  or  possibly 
stomach. 

A  pain  which  was  originally  felt  only  at  the  seat  of 
injury,  and  which  rapidly  spreads  to  a  lower  part  of  the 
abdomen,  is  strongly  suggestive  of  the  escape  of  visceral 
contents  and  their  movement  downwards  by  the  force 
of  gravity. 

A  carter  was  struck  in  the  epigastrium  by  the  pole  of  a 
waggon.  When  seen  five  hours  later  a  slight  bruise  marked 
the  exact  position  of  the  blow.  The  pain,  which  had  at  first 
been  in  the  epigastrium,  was  now  felt  chiefly  in  the  lower 
abdomen.  The  rectus  muscles  were  very  rigid.  The  abdo- 
men was,  on  these  grounds,  immediately  opened,  and  an 
extensive  rupture  of  the  second  portion  of  the  duodenum 
was  discovered. 

Distension  of  the  abdomen  is  a  common,  but  gene- 
rally late,  sign  of  severe  abdominal  injury.  It  is  usually 
a  sign  of  very  grave  import,  suggesting  a  rupture  of 
some  hollow  viscus,  and  consequent  peritonitis.  But 
not  necessarily  so.  It  may  be  due  merely  to  bruising 
of  the  intestines. 

The  detection  of  free  gas  and  free  liquid  in  the 
peritoneal  cavity  is  naturally  of  much  importance. 
Free  gas  is  best  detected  by  careful  examination  of 
the  liver  dulness. 

Free  liquid  means  either  the  escape  of  the  liquid 
contents  of  the  stomach  (very  rare)  or  of  the  bladder 
(seldom  in  quantity  sufficiently  large  to  cause  dulness 
on  percussion)  ;  or  it  means  blood  (very  common)  ;  or  it 
is  due  to  the  effusion  of  serous  fluid  poured  out  from 
the  peritoneum.  In  the  latter  case  the  fluid  appears 
later  and  is  due  to  inflammatory  changes.     Frequently 


INJURIES    TO    THE    ABDOMEN.  305 

the  fluid  found  in  the  abdomen  some  hours,  or  a  day  or 
two,  after  the  accident  is  a  mixture  of  blood  and  serous 
fluid.  That  the  liquid  is  free  is  shown  by  the  usual 
test  of  alteration  of  the  dulness  with  the  altered  position 
of  the  patient. 

Fluid  poured  out  into  the  retro-peritoneal  cellular 
tissue  may  also  come  forwards  into  the  flanks  and  give 
rise  to  dulness,  but  in  this  case  the  area  of  dulness 
does  not  vary  with  the  position  of  the  patient.  Retro- 
peritoneal collections  of  fluid  are  at  first  either  blood 
(derived  either  from  the  kidney  or  occasionally  from 
the  great  vessels  of  the  abdomen  lying  behind  the 
peritoneum),  or  else  urine  derived  from  the  kidney  or 
ureter.  In  later  stages  inflammatory  fluids  (pus)  may 
be  the  cause  of  dulness. 


5.  Evidence  from  Excreta  and  Ejecta. 

Vomiting  is  common  in  all  forms  of  abdominal 
injury,  and  does  not  help  much  in  the  differential 
diagnosis  of  the  part  injured.  Vomiting  of  blood  may 
point  to  a  laceration  of  the  mucous  membrane  of  the 
stomach,  but  is  not  common.  Severe  ruptures  of  the 
stomach  are  not  usually  attended  with  the  vomiting  of 
blood  in  any  quantity. 

The  presence  of  blood  in  the  motions  (melgena) 
may  similarly  point  to  a  lesion  of  the  intestine.  But 
in  recent  injuries  of  the  intestines  blood  is  rarely 
passed  by  the  bowel,  and  is  of  but  little  importance  in 
the  diagnosis.  At  a  later  stage,  some  days  after  the 
injury,  it  is  not  uncommon  for  the  motions  to  contain 
dark,  tarry  material  (altered  blood),  which  points  to  an 
intestinal  contusion. 

u 


3o6  SURGICAL    DIAGNOSIS. 

HaBinaturia  is  extremely  common  as  the  result  of 
an  injury  to  the  kidney,  and  is  the  most  valuable  sign 
of  such  an  injury.  Indeed,  in  every  case  of  abdominal 
injury  a  careful  examination  of  the  urine  should  be 
made. 

Rupture  of  the  kidney  is  on  this  account  more  easy 
to  diagnose  with  certainty  than  that  of  any  other 
abdominal  viscus. 


6.  Exploratory  Operation. 

In  many,  perhaps  in  most,  cases  of  severe  abdominal 
injury  without  external  wound,  it  is  quite  impossible  at 
first  to  make  any  certain  diagnosis.  From  the  nature 
and  situation  of  the  injury  we  may  suspect  that  such 
and  such  a  viscus  has  been  wounded.  But  the  absolute 
proof  is  rarely  forthcoming  at  the  time  at  which  the 
diagnosis  ought  to  be  made,  if  any  operative  treatment 
is  to  be  undertaken  with  a  reasonable  prospect  of 
success.  Early  diagnosis  is  all  important  in  those 
cases  in  which  operation  affords  the  only  chance  of 
recoverv. 

In  order  to  make  a  really  early  diagnosis  we  must 
either  depend  upon  general  considerations  such  as  the 
nature  and  situation  of  the  injury,  or  we  must  watch 
very  carefully  to  observe  the  first  beginnings  of  the 
definite  and  really  serious  symptoms  due  to  the  injury 
itself.  The  symptoms  caused  by  a  severe  abdominal 
lesion  are  mainly  those  of  hgemorrhage  and  those  of 
septic  absorption.  Injuries  to  the  solid  organs  such 
as  the  liver  and  spleen,  and  to  the  large  vessels  of  the 
abdomen,  cause  hgemorrhage.  Injuries  to  the  hollow 
viscera,  such  as  the  stomach  and  intestines,  cause  sepsis. 


INJURIES    TO    THE    ABDOMEN.  307 

Pallor,  smallness  and  quickness  of  pulse,  and  fluid  in 
the  peritoneal  cavity  are  the  signs  indicating  hsBmor- 
rhage.  A  steadily  rising  pulse  rate  without  other 
evidence  of  haemorrhage  is  the  most  valuable  early  sign 
of  septic  absorption. 

Increasing  abdominal  distension  and  sometimes  in- 
creasing temperature  are,  of  course,  common  in  late 
stages,  but  are  not  of  much  use  in  making  a  really 
early  diagnosis.  If  the  surgeon  is  in  doubt  whether  he 
ought  to  do  an  exploratory  operation  and  decides  to 
wait,  he  will  do  well  to  have  the  pulse,  temperature  and 
respiration  recorded  every  hour  upon  a  chart,  for  the 
first  twenty-four  hours  at  least.  The  circumference  of 
the  abdomen  should  also  be  measured  from  time  to  time 
to  detect  increasing  distension. 

Exploratory  operation  should  be  undertaken — 

(i)  If  the  history  of  the  accident  and  the  rigidity  of 
the  abdominal  muscles  are  such  as  to  make  it  clear  that 
a  severe  injury  has  been  inflicted  upon  the  abdomen, 
even  if  there  are  as  yet  no  definite  symptoms  of  either 
haemorrhage  or  sepsis.  A  typical  example  would  be  a 
severe  kick  from  a  horse  in  the  centre  of  the  abdomen. 

(2)  If  the  signs  and  symptoms  indicate  that  serious 
intra-abdominal  hsemorrhage  is  going  on. 

(3)  If  the  rising  pulse-rate  and  other  symptoms 
indicate  that  septic  absorption  is  beginning,  that  is,  that 
a  hollow  viscus  has  been  penetrated  (generally  the 
intestine). 

The  surgeon  must  also  be  guided  by  the  age  of  the 
patient  and  the  nature  of  the  abdomen  upon  which  he 
proposes  to  operate.  An  operation  upon  a  fat  or  dis- 
tended abdomen  is  far  more  serious  than  an  operation 
upon  one  in  which  these  conditions  are  not  present. 


308  SURGICAL    DIAGNOSIS. 

It  must  be  remembered  also  that  an  exploratory 
operation  in  itself  necessarily  does  harm,  and  that  it  is 
of  no  use  unless  it  can  be  immediately  followed  up  by 
a  proceeding  intended  as  a  curative  measure.  The 
good  that  can  be  done  by  an  operation  for  abdominal 
injury  is  practically  narrowed  down  to  (i)  the  arrest  of 
haemorrhage  by  tying  vessels,  or  by  plugging  with 
gauze ;  (2)  the  closure  of  a  wound  of  a  hollow  viscus 
by  sewing  it  up,  and  thus  preventing  further  extrava- 
sation of  septic  material  ;  (3)  removal  of  any  septic 
material  that  has  already  been  extravasated. 

An  operation  that  does  none  of  these  three  things 
does  more  harm  than  good. 


CHAPTER  XXXIII. 

INJURIES  TO  THE  PELVIS. 

Injury  to  the  pelvis  may  involve  fracture  of  the  bones 
with  or  without  damage  to  the  viscera.  Or  the  viscera 
alone  may  be  damaged  by  direct  wound  or  by  rup- 
ture. 

In  examining  for  fracture  of  the  pelvis  it  is  best  to 
press  the  ossa  innominata  together;  this  will  show  a 
characteristic  looseness  in  most  cases  of  fracture.  Or 
pressure  from  before  backwards  upon  one  anterior 
superior  spine  v^^ill  show  the  same  thing.  Crepitus  may 
be  obtained  also  by  either  of  these  methods,  but  is  by 
no  means  essential  for  the  diagnosis. 

Fractures  breaking  ofi'  the  crest  of  the  ilium  are 
usually  very  easily  detected  by  the  great  looseness  of 
the  detached  fragment. 

The  commonest  fracture  of  the  pelvis  is  one  which 
passes  through  the  obturator  foramen  in  front,  and 
through  or  near  the  sacro-iliac  joint  behind. 

This  form  is  best  detected  by  carefully  passing  the 
finger  along  the  crest  and  horizontal  ramus  of  the  pubis 
and  along  the  margin  of  the  pubic  arch.  In  both  these 
places  the  bones  are  comparatively  superficial  and  easily 
examined.  As  a  fracture  of  the  pelvis  almost  always 
traverses  one  or  other   or  both  of  them,  it  can  usually 


310  SURGICAL   DIAGNOSIS. 

be  very  easily  detected.  In  a  doubtful  case  much  help 
may  be  obtained  by  passing  a  finger  into  the  rectum 
or  vagina,  and  examining  the  pelvis  from  within. 

X-rays  are  of  comparatively  little  practical  value  in 
the  detection  of  fractures  of  the  pelvis  on  account  of 
the  difficulty  of  applying  them  to  this  bulky  region  of 
the  body. 

In  every  case  of  injury  to  the  pelvis  or  its  neigh- 
bourhood the  condition  of  the  viscera  should  be 
considered. 

The  bladder  is  likely  to  be  ruptured  if  it  was  full 
at  the  time  of  the  accident.  If  the  bladder  was  known 
to  have  been  full  at  the  time  of  the  accident,  the 
patient  has  not  passed  water  since,  and  the  distended 
bladder  cannot  be  felt  on  bimanual  examination,  then 
rupture  of  the  bladder  may  be  diagnosed.  The  diagnosis 
will  be  confirmed  by  passing  a  catheter.  Probably  only 
a  small  quantity  of  blood-stained  urine  will  be  withdrawn. 

It  must  be  remembered  that  the  symptoms  due  to 
the  escape  of  urine  into  the  abdomen  are  at  first  usually 
by  no  means  severe.  In  a  doubtful  case  of  rupture  of 
the  bladder  it  may  be  advisable  to  inject  a  measured 
quantity  of  fluid  into  the  bladder.  If  the  whole  of  this 
fluid  cannot  be  withdrawn  again  by  catheter,  the  infer- 
ence is  that  some  of  it  has  passed  through  a  rent  in  the 
bladder. 

If  the  bladder  be  ruptured  extraperitoneally  into  the 
cellular  tissue  behind  the  pubic  bones,  the  diagnosis 
is  more  difficult.  In  a  fracture  of  the  anterior  part  of 
the  pelvis,  the  possibility  of  this  accident  being  due  to 
a  sharp  fragment  of  bone  being  driven  into  the  bladder 
must  be  borne  in  mind.  The  passage  of  a  catheter 
will  probably  reveal  the  presence  of  blood-stained  urine. 


INJURIES    TO    THE    PELVIS.  3 II 

Swelling  will  soon  make  its  appearance  behind  and 
above  the  pubic  bones,  due  to  infiltration  of  the  cellular 
tissue  with  urine,  or  urine  and  blood.  Infiltration  of 
the  same  part  with  blood  alone  is  common  in  cases  of 
fractured  pelvis,  and  much  difficulty  may  be  experi- 
enced in  determining  the  nature  of  such  a  swelling. 
Careful  observation  of  the  pulse  and  temperature  for  a 
few  hours  will  probably  help  in  the  diagnosis.  Effusion 
of  urine  is  more  likely  to  affect  these  than  is  a  mere 
effusion  of  blood. 

In  a  doubtful  case  the  •  parts  must  be  explored 
through  an  incision  in  the  middle  line  immediately 
above  the  pubes. 

In  all  cases  of  injury  to  the  pelvic  regions,  and  espe- 
cially to  the  perineum,  attention  should  be  directed  to 
the  state  of  the  urethra. 

Kupture  of  the  urethra  does  not  necessarily  cause 
any  symptoms  of  which  the  patient  will  complain.  If 
there  is  bleeding  from  the  urethra  it  is  probable  that 
attention  will  be  called  to  the  part.  But  if  there  is  no 
external  bleeding,  it  is  not  difficult  to  overlook  a  serious 
rupture  of  the  urethra  until  extravasation  of  urine  has 
occurred,  and  the  gravity  of  the  case  has  been  greatly 
increased.  If  the  surgeon's  attention  has  been  directed 
to  the  urethra,  there  is  usually  but  little  difficulty  in 
making  the  diagnosis  of  rupture.  Inability  or  difficulty 
in  the  passage  of  a  catheter,  and  the  presence  of  tender- 
ness and  perhaps  swelling  in  the  perineum,  will  indicate 
the  nature  of  the  injury.  Confirmation  of  the  diagnosis 
will  be  afforded  by  the  operation  which  in  most  cases 
has  to  follow  at  once. 

In  the  later  stages  of  rupture  of  the  urethra,  when 
extravasation  has  set  in,  the  symptoms  are  the  same  as 


312  SURGICAL    DIAGNOSIS. 

those  of  extravasation  due  to  non-traumatic  rupture 
connected  with  stricture  of  the  urethra. 

Wounds  of  the  rectum  are  rarely  connected  with 
fracture  of  the  pelvis.  They  are  usually  produced  by 
falls  upon,  or  blows  from,  sharp  pointed  bodies.  They 
present  but  little  difficulty  in  diagnosis,  provided  that 
a  thorough  examination  of  the  v^ound  be  made. 


CHAPTER   XXXIV. 

INJURIES  TO  THE  SPINE. 

The  diagnosis  of  fracture-dislocation  of  the  spine  is 
made  partly  by  direct  physical  examination  of  the  injured 
part,  as  in  the  case  of  fractures  of  most  other  bones, 
but  mainly  by  inference  from  the  symptoms  produced 
by  the  concomitant  damage  to  the  spinal  cord. 

In  examining  a  case  of  suspected  fracture  of  the 
spine,  the  utmost  care  should  be  taken  that  more  harm 
be  not  done  to  the  spinal  cord  by  causing  further  dis- 
placement of  the  broken  or  dislocated  portions  of  the 
spinal  column. 

The  patient  must  not,  of  course,  be  allowed  to  make 
any  attempt  to  sit  up.  The  examination  of  the  back 
must  be  made  by  passing  the  hand  under  the  patient's 
back  and  carefully  feeling  the  spine.  Irregularity  of 
the  bones,  a  prominent  angle,  or  a  gap  between  the 
vertebrae,  may  show  an  obvious  fracture.  It  may  be 
permissible  to  roll  the  patient  gently  over  on  to  his  side 
for  the  purpose  of  inspection  of  the  back,  but  this  is 
seldom  necessary  or  desirable,  unless  the  presence  of  an 
external  wound  requires  it. 

We  have  to  discuss  the  diagnosis  of  the  injury  (i)  to 
the  vertebral  column,  (ii)  to  the  spinal  cord. 

(i)  The  slighter  injuries  to  the  vertebral 
column,  such  as  rupture  of  ligaments  or  muscles,  or 


314  SURGICAL   DIAGNOSIS. 

fracture  of  outstanding  processes  of  bone,  may  give  rise 
to  few  or  no  definite  signs  of  injury  beyond  some  pain, 
tenderness,  and  stiffness  of  the  affected  part. 

Even  a  fracture  througli  the  body  of  a  vertebra  may 
occur  without  causing  any  definite  signs  of  its  presence 
if  the  spinal  cord  have  not  been  injured,  and  no  displace- 
ment of  bone  have  occurred.  Care  must  be  taken  not  to 
conclude  too  readily  that  no  serious  injury  to  the  bones 
has  occurred  merely  because  no  definite  signs  of  such 
injury  exist.  In  young  people  especially  is  it  important 
to  remember  that  a  neglected  case  of  slight  injury  to 
the  spine  often  leads,  a  few  months  later,  to  ver}^  definite 
caries. 

Practure  of  a  spinous  process  is  usually  easily  diag- 
nosed by  the  mobility  of  the  broken  process  and  by  the 
occurrence  of  crepitus. 

Fracture  across  the  vertebral  column  without  dis- 
placement and  without  symptoms  of  spinal  cord  mischief 
may  often  be  diagnosed,  not  only  by  the  pain  and  ten- 
derness and  loss  of  power  of  movement  in  the  spine 
itself,  but  especially  by  the  severe  pain  along  the  course 
of  the  spinal  nerves  that  emanate  from  the  injured 
portion  of  the  column.  A  fracture  which  involves  an 
intervertebral  foramen  is  extremely  likely  to  cause  irri- 
tation of  the  nerve  passing  through  that  foramen,  and 
consequently  to  cause  pain  referred  to  its  peripheral 
distribution. 

(ii)  Injury  to  the  spinal  cord,  with  or  with- 
out fracture  or  dislocation. 

It  is  possible  that  slight  and  transient  weakness  of 
the  lower  limbs  may  occur  with  fracture  of  the  bones 
owing  to  so-called  ''  concussion  "  of  the  cord.  Whether 
true  concussion  ever  occurs  without  a  gross   lesion  of 


INJURIES    TO    THE    SPINE.  315 

the  spinal  cord  is,  however,  a  doubtful  and  disputed 
point.  Probably  it  does  not.  Certainly,  in  most  of  the 
cases  of  so-called  mere  concussion  of  the  cord  there  has 
been  an  actual  lesion  of  the  cord  itself  from  haemorrhage 
or  bruising. 

It  is  possible  for  a  spinal  cord  to  be  damaged  without 
injury  to  the  bones,  as  in  the  case  of  a  stab-wound  or 
even  in  a  case  of  a  fall  or  a  blow  upon  the  spine. 

Incised  wOTinds  of  the  spinal  cord  are  very  rare, 
but  when  they  do  occur  are  easily  diagnosed  by  the 
physiological  effects  produced,  according  to  the  por- 
tion of  the  spinal  cord  that  has  been  divided. 

A  wound  that  passes  near  to,  but  does  not  actually 
involve,  the  spinal  cord  may  nevertheless  cause  para- 
lytic symptoms  from  haemorrhage,  or,  at  a  later  stage, 
from  inflammation.  The  diagnosis  is  made  partly  by 
the  fact  that  the  effects  of  a  direct  wound  appear 
instantly,  while  those  caused  by  haemorrhage,  and 
which  are  due  to  gradually  increasing  pressure,  do 
not  supervene  until  after  the  lapse  of  an  appreciable 
interval  of  time.  Paralytic  symptoms  due  to  inflam- 
matory changes  naturally  are  still  later  in  making  their 
appearance. 

The  diagnosis  is  made  also  to  a  certain  extent  by 
the  fact  that  the  wound  involves  a  particular  spot 
in  the  cord,  whereas  haemorrhage  and  inflammation 
generally  affect  a  wider  area,  a  great  length  of  the 
spinal  cord.  The  localisation  of  the  seat  of  injury  is 
therefore,  in  the  latter  case,  not  quite  so  accurate. 

Far  more  common  than  incised  wounds  of  the 
spinal  cord  are  the  contused  wounds  accompanying 
fracture  or  fracture-dislocation.  The  most  important 
question  that  we  have  to  determine  when  called  to  a 


3l6  SUEGICAL    DIAGNOSIS. 

case  of  fractured  spine  is  usually,  Has  the  cord  been 
completely  crushed  or  not  ?  If  not  completely  crushed, 
has  it  been  partly  crushed,  or  are  the  nervous 
symptoms  due  entirely  to  haemorrhage  or  other 
changes  occurring  outside  the  spinal  cord  ? 

If  the  vertebral  column  has  been  broken  comxpletely 
across,  the  delicate  spinal  cord  seldom  escapes  injury. 
In  the  commonest  case  the  cord  is  completely 
crushed  opposite  the  seat  of  the  fracture.  At  the 
moment  of  the  accident  the  upper  portion  of  the 
spinal  column  is  usually  carried  forwards,  so  that  the 
cord  is  nipped  between  the  upper  and  posterior  edge 
of  the  body  of  the  vertebra  below  the  seat  of  frac- 
ture, and  the  lamina  of  the  vertebra  above.  This 
displacement  of  the  bones  may  have  been  only 
momentary.  Frequently  the  bones  slip  back  again 
into  their  normal  positions  directly  the  strain  upon 
them  has  been  taken  off.  But  in  the  meantime  the 
cord  has  been  nipped  and  crushed.  In  such  a  case  of 
fracture-dislocation  as  this,  the  evidence  of  complete 
crush  is  usually  only  too  plain  ;  the  paralysed  lower 
limbs,  the  angesthesia,  the  absence  of  deep  reflexes, 
the  zone  of  hyperagsthesia,  and  later  the  bladder 
troubles,  usually  form  a  clinical  picture  which  is  un- 
mistakable. 

An  important  j)oi^^fc  ^^  the  determination  whether 
the  paralysis  of  the  lower  limbs  in  a  given  case  of  frac- 
ture of  the  spine  is  due  to  complete  transverse  division 
or  merely  to  bruising  lies  in  the  condition  of  the  deep 
reflexes. 

If  the  deep  patellar  reflexes  are  present,  it  may  be 
concluded  that  the  cord  has  not  been  completely 
crushed.     If  they  are  not  present,  no  definite  conclusion 


INJURIES    TO    THE    SPINE.  317 

either  way  can  be  drawn  until  some  little  time  has  been 
allowed  to  elapse.  In  cases  of  bruising  without  com-* 
plete  division  of  the  cord,  the  deep  reflexes  may  be 
absent  for  a  time  and  then  reappear. 

The  exact  diagnosis  of  the  seat  of  lesion  in  the  cord 
is  the  more  easily  made  when  the  lesion  is  confined  to  a 
definite  and  small  region  of  the  cord.  If  the  injury  is 
accompanied  by  much  haemorrhage  or  followed  by  an 
ascending  inflammation  the  nerve  symptoms  will 
naturally  point  to  a  region  higher  than  the  actual  seat 
of  fracture. 

Hsemorrliage  around  the  cord,  the  result  of  injury 
to  the  vertebral  column,  usually  takes  place  outside 
the  theca  vertebralis,  the  blood  being  derived  from  the 
fractured  surfaces  of  bone  and  from  the  plexus  of 
large  veins  that  lines  the  vertebral  canal. 

Haemorrhage  around  the  spinal  cord  is  to  be  diagnosed 
mainly  by  the  mode  of  onset  of  the  paralytic  symptoms. 
They  come  on  within  a  few  hours  of  the  accident,  and 
gradually  become  more  severe.  If  the  haemorrhage 
continues  and  is  passing  up  the  vertebral  canal,  then 
the  paralysis  ascends  in  proportion. 

The  symptoms  of  hemorrhage  are  to  be  distinguished 
from  those  due  to  direct  injury  to  the  cord  by  their 
later  onset.  They  are  distinguished  from  those  due  to 
inflammatory  changes  by  their  earlier  onset.  Paralytic 
symptoms  appearing  days  or  weeks  after  the  accident 
are  not  likely  to  be  due  to  anything  but  inflammatory 
conditions.  It  must  be  remembered  that  in  the  adult 
the  spinal  cord  does  not  extend  lower  than  the  first 
lumbar  vertebra.  Fractures  below  this  level  do  not 
involve  the  cord  itself,  but  only  the  nerves  lying  in  the 
canal,  but  given  ofi"  at  a  higher  level. 


CHAPTER  XXXV. 

INJURIES  TO  THE  LIMBS. 

The  diagnosis  of  the  various  injuries  to  the  limbs  is  to 
be  made  in  most  cases  by  the  simple  and  judicious 
application  of  anatomical  knowledge  and  common  sense. 
A  bone  is  broken.  It  can  no  longer  act  as  a  rigid  bar  ; 
movements  then  which  depend  upon  the  rigidity  of  this 
bar  can  no  longer  be  executed.  The  two  or  more  pieces 
into  which  the  bone  has  been  broken,  unless  impacted, 
can  be  moved  upon  each  other.  The  broken  fragments 
are  more  or  less  separated  from  each  other  ;  a  gap  exists 
between  them  which  is  more  or  less  perceptible  to 
the  touch,  as  in  common  transverse  fracture  of  the 
patella.  Or  the  broken  ends  overlap  and  the  bone 
thus  appears  to  be  shorter  than  it  should  be.  One  or 
other  of  the  broken  ends  may  stand  out  prominently 
and  can  be  seen  or  felt.  Or  it  can  be  felt  on  deep 
palpation. 

The  broken  ends  may  be  in  contact,  or  can  easily 
be  brought  into  contact ;  crepitus  is  then  produced. 
Crepitus  must  be  distinguished  from  the  grating  of  a 
neighbouring  rheumatic  joint,  and  from  the  creaking  of 
inflamed  or  roughened  synovial  sheaths.  Crepitus  may 
be  absent  if  the  ends  of  the  fragments  overlap  much  or 
are  separated  by  muscle  or  other  soft  structures. 

A  recent  fracture  is  always  accompanied  by  a  certain 


INJURIES    TO    THE    LIMBS.  319 

amount  of  ha3morrhage  either  from  the  broken  ends  of 
the  bone  or  from  laceration  of  the  neighbouring  soft 
parts.  This  extravasation  of  blood  may  cause  consider- 
able swelling  around  the  fracture,  and  render  the 
detection  of  the  fracture  more  difficult.  Sometimes  this 
hgemorrhage  is  in  itself  evidence  of  fracture.  Thus  a 
large  blood  extravasation  obscuring  the  patella  may  be 
taken  as  evidence  of  fracture  of  that  bone,  even  when  the 
bone  itself  cannot  be  felt,  provided  that  it  is  not  due  to 
a  direct  blow  upon  the  knee,  and  is  associated  with  the 
usual  history  which  accompanies  a  fracture  of  the 
patella. 

Fractures  extending  into  joints  may  often  be  diag- 
nosed, or  at  least  suspected,  from  the  accompanying 
effusion  of  blood  into  the  joint. 

In  the  examination  of  a  case  of  supposed  fracture, 
then,  a  careful  comparison  should  be  made  between  the 
affected  limb  and  the  corresponding  part  on  the  oppo- 
site side  of  the  body.  The  situation  and  relative 
position  of  the  various  bones  and  parts  of  the  bones 
should  be  examined.  Special  attention  should  be  paid 
to  the  various  bony  points  that  are  most  easily  seen  or 
felt.  Those  parts  of  the  bone  which  are  most  easily 
accessible  to  direct  examination,  because  less  covered  by 
muscle  and  other  soft  structure,  should  be  carefully 
investigated.  Thus  a  fracture  of  the  surgical  neck  of 
the  humerus  can  often  be  easily  detected  when 
examined  from  the  axillary  aspect,  while  examination 
through  the  thick  deltoid  muscle  may  fail  to  reveal  its 
presence. 

Separation  of  an  epiphysis  is  an  affection  that 
is  diagnosed  chiefly  by  the  age  of  the  patient,  by  the 
situation  in  which   the  bone  has  been  injured,  and  by 


320  SURGICAL    DIAGNOSIS. 

the  fact  that  the  crepitus,  if  obtainable,  is  not  so  dis- 
tinct and  clear  as  in  the  case  of  a  fracture. 

The  value  of  examination  by  means  of  X-rays  in  the 
detection  of  fractures  and  separations  of  epiphyses  is 
of  course  obvious. 

A  previous  study  of  X-ray  photographs  of  normal 
bones  at  various  ages  is  useful,  as  it  is  not  always  easy 
to  read  X-ray  photographs  correctly. 

Dislocations  must  be  detected  by  the  application 
of  principles  similar  to  those  which  guide  us  in  the 
detection  of  fractures. 

Does  the  end  of  the  bone  occupy  its  normal  position  ? 
that  is,  does  it  bear  its  normal  relation  to  surrounding 
bony  points  ? 

Can  the  end  of  the  bone  be  felt  to  occupy  some 
position  other  than  the  normal  ? 

A  correct  answer  to  these  two  questions  will  solve 
the  problem  whether  there  is  a  dislocation  or  not. 

If  the  dislocated  end  of  the  bone  occupies  some  very 
deep  situation  beneath  a  mass  of  fat,  muscle  or  blood 
extravasation,  so  that  it  cannot  be  plainly  felt,  then 
examination  of  the  other  parts  of  the  bone  will  indicate 
its  situation. 

Careful  examination  of  the  direction  of  the  axis  of 
the  shaft  of  the  humerus  may  indicate  that  the  head  of 
that  bone  is  in  the  axilla,  rather  than  in  the  glenoid 
cavity.  Investigation  of  the  direction  in  which  the 
internal  condyle  of  the  femur  looks  will  indicate  the 
position  of  the  head  and  neck  of  that  bone  in  a  case 
where  these  structures  cannot  be  plainly  felt. 

The  presence  of  the  dislocated  bone  in  the  wrong 
place  may  cause  symptoms  due  to  pressure  upon  soft 
parts.     Thus  the  dislocated  end  of  the  humerus  may 


INJURIES    TO    THE    LIMBS.  32 1 

cause  much  pain  down  the  arm,  which  may  help  in  the 
diagnosis. 

The  movements  of  a  joint  are  always  more  or  less 
restricted  when  a  dislocation  has  occurred  at  that 
joint. 

Injuries  to  Joints. — Besides  dislocations,  joints 
may  be  affected  by  strains  which  tear  the  ligaments, 
or  bruise  the  synovial  membrane,  or  cause  rupture 
of  semilunar  cartilages.  Rupture  of  ligaments  without 
dislocation  is  indicated  by  pain  over  the  affected  part ; 
by  blood  extravasation  more  or  less  marked,  according 
to  the  severity  of  the  injury  ;  and  by  unnatural  looseness 
or  weakness  of  the  joint. 

All  injuries  to  joints  are  likely  to  be  followed  by 
effusion  into  the  joint.  This  effusion  consists  of  blood 
when  it  immediately  follows  the  injurj^.  If  appearing 
after  an  interval  of  time  it  is  a  serous  effusion,  or  a 
mixture  of  blood  and  serum. 

Wounds  of  joints  are  diagnosed  partly  by  effusion 
into  the  joint,  partly  by  the  escape  of  the  contents  of 
the  joint  (synovia),  and  partly  by  general  considerations 
as  regards  the  situation,  direction,  and  depth  of  the 
wound. 

Muscles  may  be  ruptured  or  wounded. 

Rupture  of  muscle  is  caused  by  violent  and  sudden 
overstrain,  as  when,  during  a  fall,  a  patient  catches 
with  extended  arm  at  a  bar,  or  when  a  muscle  is 
suddenly  and  violently  put  into  action. 

In  either  case  the  diagnosis  is  not  difficult  to  make. 
The  muscle  is  unable  properly  to  perform  its  function, 
and  when  an  attempt  is  made  to  put  the  muscle  into 
action,  that  end  of  it  to  which  the  motor  nerve  is 
attached    shortens    and    swells   up,   revealing    a    gap 

X 


32  2  SURGICAL    DIAGNOSIS. 

between  the  broken  ends.  This  gap  in  a  case  of  recent 
rupture  generally  appears  as  a  soft  swelling,  owing  to 
the  extravasation  of  blood  into  it.  In  a  case  of  old 
rupture,  when  the  blood  has  been  absorbed  and  atrophy 
of  the  distal  ]3ortion  has  occurred,  the  diagnosis  of  the 
condition  is  obvious. 

Laceration  or  wound  of  the  fascial  sheath  of  a 
muscle  m.Sij  lead  to  hernia.  In  this  case  a  well- 
defined  soft  elastic  mass  will  be  felt  to  project  through 
the  aperture.  This  mass  contracts  when  an  attempt 
is  made  to  put  the  muscle  into  action. 

Wounds  of  tendons  demand  but  brief  mention. 
Any  wound  in  the  neighbourhood  of  a  tendon  should 
call  for  careful  investigation  to  see  if  the  actions  of  the 
tendons  can  be  properly  executed. 

In  every  case  of  injury  to  a  limb  especial  attention 
should  be  paid  to  the  condition  of  the  main  vessels 
and  nerves. 

Wounds  or  contusion  of  arteries  are  generally  easily 
detected  by  the  effect  on  the  pulse  below ;  sometimes 
also  by  the  extravasation  of  blood  that  takes  place  at 
the  wounded  spot. 

Whether  a  punctured  wound  involves  a  main  artery 
or  not  is  usually  settled  by  a  consideration  of  these 
points.  It  must  be  remembered,  however,  that  a  wound 
of  a  branch  close  to  its  origin  from  the  main  artery 
may  cause  very  severe  haemorrhage  and  easily  be  mis- 
taken for  a  wound  of  the  main  artery  itself. 

Wounds  and  other  injuries  of  nerves  are  generally 
easily  detected  if  care  be  taken  to  examine  properly. 
The  motor  paralysis  and  the  anaesthesia  over  the  area 
supplied  by  the  nerve  are  usually  sufficient  for  the 
diagnosis.      Cases    of    partial    wound    or    temporary 


INJURIES    TO    THE    LIMBS.  323 

damage  from  crushing  are  more  difficult  to  diagnose. 
Careful  examination  of  the  exact  symptoms  will,  how- 
ever, usually  suffice  to  obviate  risk  of  error . 

The  late  involvement  of  nerves  in  contracting  scars 
generally  gives  rise  to  considerable  pain  and  some 
partial  motor  or  sensory  paralysis. 


INDEX. 

Abdomen — 

Abscess  in,  35 
Anterior  wall  of, 
Swellings  in, 

Skin  or  subcutaneous  tissues,  of,  135-136 
Muscular  and  aponeurotic  layers,  in,  136-138 
Swellings  behind,  140-143 
Distension  of,  307 
Enlargement — 

General  and  uniform,  causes  of — 

Fluid  in  peritoneal  cavity,  130-133 
Gaseous  distension  of  intestines,  129-130 
Obesity,  129-130 
Tumours,  133-134 
History  of,  125-6 
Local  swellings  in  anterior  abdominal  wall.  See  suhheading. 

Anterior  wall 
Eelation  to  muscles  of  anterior  abdominal  wall,  127 
Single   organ,  involving,  145-146.     See  also  LiVER,  Gall- 

BLADDEE,  &C. 

Exploratory  operation  on,  38-39,  307-30S 
Glandular  enlargement  in  groin  due  to  sore  on,  273 
Injury  to — 

Operation  for,  scope  of,  308 
Viscera,  evidence  of  injury  to, 

Blood  in  motions,  305 

Distension,  304 

General  evidence,  301-302 

Hsematuria,  306 

Haemorrhage,  306-307 

Local  tenderness,  302-303 

Pain,  severe,  303-304 

Eigidity  of  muscles,  303 

Septic  absorption,  307-308 

Vomiting,  305 
Wall,  299-300 
Local  disease  of,  pain  from,  158 
Pain  in.     See  Abdominal  Pain 

Physical  examination  of,  inspection,    127-128;  palpation,  128, 
182;  percussion,  128-129  ;  auscultation,  129 


326  INDEX. 

Abdominal  Pain — 

Causes  of  sudden  severe  attack,  159-166 

Character  of,  diagnostic  value  of,  158-159 

Referred,  156-157,  265 

Situation  of,  diagnostic  value  of,  156-158 
Abductor  paralysis,  90 
Abscess — 

Abdominal,  35 

Alveolar,  80 

Bone,  of,  242 

Brain.     See  Cerebral  Abscess 

Breast,  of — 

Mammary,  pain  from,  116 

Post-mammary,  breast  enlargement  due  to,  118 

Pus  discharged  from  nipple  in,  124 

Signs  of,  119 

Ear,  in,  55 

Gas  containing,  181 

Inflamed  aneurism  simulating,  278 

Inflammation  of  glands,  due  to,  272 

Intra-peritoneal,  141-142,  220,  232-233.  299 

Ischiorectal,  196,  270 

Joints,  soft  parts  near,  254 

Leucocytosis  with,  32 

Loin,  chronic  abscess  of,  simulating  kidney  swelling,  145-146 

Pelvic,  extension  to  urinary  tract,  125 

Perinephric,  215,  228,  270 

Prostate,  of,  218 

Rectal,  199,  202 

Retroperitoneal,  143-144 

Scrotal,  233 

Septic,  tapping  of,  37 

Spinal,  267-270 

Testicle,  in  or  near,  236 

Urethra,  discharging  into,  223 
Accessory  sinus  of  nose,  disease  of,  45 

Thyroid,  tumours  of,  106 
Acromegaly,  enlargement  of  bone  with,  239-240 
Actinomycosis,  fungi  in  discharges  from,  30 
Addison's  disease,  153 
Adenoids,  43,  47 
Adenomata — 

Breast,  of,  117,  121 

Palate,  of,  80 

Thyroid  gland,  of,  110-112 
Age- 
Importance  of  considering,  in  diagnosis,  7-8 

Intestinal  obstruction,  evidence  in  determining  nature  and  seat 
of,  168-169 

Perforative  peritonitis,  influence  on  causation  of,  163 
Albuminuria,  207,  209,  213,  225 
Alveolar  abscess,  80 


INDEX.  327 

Ansemia  in  uraemia,  208 

Anasarca,  132,  207 

Ansesthetics,  use  of,  in  diagnosis,  35-36 

Aneurism — 

Aortic,  107,  280  ;  abdominal  aorta,  of,  143 
Cured,  simulating  innocent  tumour,  277-278 
Diagnosis  of,  by — 
AuscultatioD,  22 
Bruit,  278 

Diminution  in  size  with  loressure  on  artery,  279 
Dulness  on  percussion,  279 
Pulsation,  276-277 
Rcintgen  rays,  opaqueness  to,  25 
Situation,  276 
Weight,  feeling  of,  279 
Dysphagia  due  to,  82,  83 
Inflamed,  simulating  abscess,  278 
Intracranial,  280 
Limbs,  of,  279 
Popliteal,  280 
Thoracic,  89,  280 
Ankle — 

Effusion  into,  249 
Lateral  movement,  257 
Ankylosis,  256,  260,  264 
Anorexia,  207 

Anterior  fossa,  fracture  of,  288 
Anthrax,  30 
Antrum  of  Highmore — 

Empyema,  49  ;  diagnosis  of,  50-51 
Inflammation  of,  65 

Nasal  disease  associated  with  disease  of,  40 
Sinus  of,  examination  of,  24 
Anuria,  207 
Anus — 

Fissure  of,  196-197 

Imperforate,  205 

Malignant  growth  of,  203 

Physical  examination,  importance  of  making,  200-201  ;  manner 

of  making,  201-202 
Protrusion  at,  significance  of,  199-200 

Symptoms  of  disease  of,  196-197  ;  questions  elucidating,  195 
Aorta,  abdominal,  aneurism  of,  143 

Thoracic,  aneurism  of,  81,  82   107,  280 
Aphonia,  89 
Appendicitis — 
Acute — 

Occasional  absence  of  leucocytosis  in,  32 
Pain,  situation  of,  157-158 
Blow  on  right  iliac  fossa,  due  to,  299 
Intestinal  obstruction  simulating  and  complicating,  167 
Perforative  peritonitis  secondary  to,  163-164 


32  8  INDEX. 

Appendix  vermiformis — 

Abscess  connected  with,  143 

Hernia  of,  185 

Inflamed  peritonitis  in  connection  with,  161 

Perforation  of.  142,  165 
Arm — 

Axillary  glandular  enlargement  due  to  sore  on,  273 

Paralysis  of  in  cerebral  abscess,  66-67 
Arteries — 

Condition  of,  with  renal  disease,  206 

Wounds  of,  300,  322 
Arthritis — 

Closure  of  jaw  due  to,  71-72 

Joints,  of,  257 
Articular  cartilage,  ulceration  of,  248 
Aryepiglottidean  folds,  91,  94,  95 
Arytenoid  cartilages — 

Displacement  of,  96 

Examination  of,  91 
Arytenoid  region,  pyriform  sw^elling  of,  95 
Ascites — 

Causation,  132 

Diagnosis,  130-133 

Localised,  140 

Malignant  disease  of  ovary  complicating,  134 
Atrophic  rhinitis,  characteristics  of,  41.  48,  52 
Atropin,  use  of,  in  diagoosis,  36 
Auditory  nerve — 

Deafness  due  to  disease  of,  54,  62 

Suppuration  extending  along  canal  of,  63-64 
Auricle,  affections  of,  53 
Auscultation,  22,  82,  129,  297-298 
Axilla — 

Glandular  swellings  in,  119-120.  272.  273 

Inflammatory  swellings  of  simulating  abscess,  272 


Back,  axillary  glandular  enlargement  due  to  sore  on,  273 
Bacteria  in  urine,  origin,  effects,  treatment,  &c.,  213-214 
Bands  of  adhesion,  intestinal  obstruction  due  to,  169,  170 
Barnard,  Mr.  H.   L.,  scheme  of  bacteriology  of  urine,  214;  on  the 

vomiting  due  to  passage  of  gall-stones.  194 
Basophile  leucocytes,  percentage  in  normal  blood,  33 
Bile  in  peritoneal  cavity.  133 
Bile-duct — 

Obstruction  of,  190 

Pancreatic  tumour,  involved  in,  150 
Bilharzia  htematobia,  18  :  ova  of,  30,  213 
Biliary  passages — 

Catarrh  of,  causing  obstruction  of  bile  duct,  190 

Inflammation  of.  191-194 


INDEX.  329 

Biliary  passages — [continued) 

Obstruction  of,  from  gall-stones — 
Common  bile  duct,  190 
Cystic  duct,  189-190,  194 
Biliousness,  164 
Bladder — 

Atony  of,  210 

Calculus  of.     See  under  CALCULI 

Capacity  of,  27,  218 

Carcinoma  of,  30,  221-222 

Distension  of,  153-154 

Dysuria,  conditions  causing,  210 

Epithelioma  of,  229 

Escape  of  liquid  from,  to  peritoneal  cavity,  304 

Examination  of,  217-218 

Fracture — dislocation  of  spine,  effect  of,  316 

Hasmaturia  derived  from  new  growth  in,  223-224,  228 

Hernia  of,  186 

Inflammation  of  mucous  membrane.     See  Cystitis 

Internal  measurement  of,  27 

Irritability  of,  126 

Papilloma  of,  heematuria  due  to,  221-222  ;  intermittent  hgema- 
turia,  229 

Pyuria  derived  from,  223-224 

Rupture  of,  133,  310-31 1 

Tubercle  of,  pyuria  and  hsematuria  due  to,  226-227 

Tumour  of — 

Malignant,  153  ;  diagnosis  between  innocent  and  malignant, 

228-229 

Uterine  swellings  simulating,  154 
Blood— 

Ascitic  fluid,  in,  132-133 

Bacteria  introduced  into  urine  from,  213-214 
Corpuscles,  estimation  of  number,  31 
Cysts — 

Abdominal  wall,  in,  136 

Peritoneal  cavity,  in,  141,  142 

Retro-peritoneal,  143 
Discharge  of,  from  anus,  signification  of,  172-173 
Effusion  of  in  :  a  joint,  250-251  ;  ruptured  bladder,  311 
Examination  of,  30-34 
Haemoglobin  in,  34 
Leucocytes  in,  varieties  of,  32-34 
Micro-organisms  in,  34 
Motions,  in,  305 
Nasal  discharge  of.  51-52 
Nipple,  discharged  from,  124 
Peritoneal  cavity,  in,  304 
Retro-peritoneai  collections  of,  305 
Urine  in.     See  HEMATURIA 
Vomited  contents  of  stomach,  in,  30 
Vomiting  of,  126,  305 


33^  INDEX. 

Blood  poisoning,  symptoms  of,  240 
Bone — 

Atrophy  of,  238-239 

Congenital  malformations,  238 

Deformity,  240 

Dislocations,  320-321 

Fractures,  318-320 

General  enlargement,  239-240 

Hardening  of,  239 

Inflammatory  affections    of,   240-242 ;    diagnosed    from   new 
growths,  242-245 

Injuries  of,  local,  243  ;  Eontgen  rays  used  for  detecting,  25 

Local  swelling  of,  240 

Softening  of,  239 

Spontaneous  fracture,  245 
Bougie,  examination  by,  84,  218,  219,  220,  223 
Brachial  plexus,  involvement    of  nerves  in   malignant  disease  of 

thyroid,  113 
Brain — 

Abscess  of.     See  Cekebral  Abscess 

Deafness  proceeding  from,  54,  62 

Injuries  to,  states  resulting  from,  284-285 
Breast — 

Abscess  of,  pus  discharged  from  nipple  in,  124 

Adenomata,  pain  from,  117 

Carcinoma  of.    See  Carcinoma,  Breast  of 

Chronic  fibroid  condition  diagnosed  from  cancer,  120 

Cysts  of,  121-122  ;  cancer  simulating,  122-123  ;  pain  from,  116, 
117 

Duct  tumours,  evidence  of,  124 

Enlargement  of,  11 7-1 18 

Fibro-adenoma  of,  121 

Inflammation  of — 

Diagnosed  from  cancer,  120 
Pain  from,  116 
Swelling  due  to,  118-119 

New  growths  of,  pain  from,  116-117 

Nipple — 

Discharge  from,  122,  123-124 
Eetraction  due  to  cancer,  123 

Pain  in — 

Diseases  of  breasts,  from,  116-117 
Eef  erred,  11 5-1 16 

Superficial  affections  of  skin  and  nipple,  124 

Tuberculous  inflammation  diagnosed  from  cancer,  11 9- 120 
Breathing — 

Difficulty  in,  from  injury  to  lung,  295 

Glossitis,  in,  73 

Injury  to  neck,  in,  129 
Bright'sfdisease,  cedema  of  larynx  due  to,  88,  94 
Broad  ligament,  uterine  swellings  simulating  swellings  of,  154 


INDEX.  331 

Cabot,  cited,  34  note 

Cfficum,  perforation  of,  162,  164 

Calculi — 

Bladder  of — 

Dysuria  due  to,  210 
Examination  for,  217 
Measurement  of,  27 
Micturition,  frequent,  caused  by,  209 
Tubercle  simulating,  210 
Urine  of,  30,  226-227 
Prostate,  of,  218 
Eenal — 

Pain  from,  situation  of,  157 
Pyuria  and  hsematuria  due  to,  226-227 
Eontgen  rays  used  for  detecting,  25 
Urine  of,  213 
Rontgen  rays  used  for  detection  of,  25,  227 
Salivary,  74 
Ureters  in,  208,  216 
Urethra  in,  220 
Calyces  of  kidney,  stone  in,  228 
Cancer.     See  Caecinoma 
Carcinoma — 

Bile  duct  obstructed  by,  190-19 1 
Bladder,  in— 

Examination  for,  217 
Hsematuria  caused  by,  221-222 
Bone,  of,  245 
Breast,  of,  1 17-123 
Floor  of  mouth,  of,  74 
Intestine,  large,  of,  137 
Laryngeal,  100-102 
Nose,  of,  52 
(Esophagus,  of,  83,  89 
Prostate,  of,  218 

Eectal,  201,  204-205  . 

Rodent,  41 
Stomach,  of,  30,  38 
Transverse  colon,  of,  139 
Caries — 

Bone,  of,  245  ;  bones  of  ear,  53 
Hip,  of,  pyuria  in  connection  with,  222 
Spinal.     See  Spine,  Caeies  op 
Carotid  artery — 

Haemorrhage  from,  290-291 

Neck  swellings  diagnosed  by  their  relation  to,  108 
Cartilage — 

Dislocated  semilunar  simulating  loose,  252-253 
Loose,  within  a  joint,  252-253 
Casts  in  urine,  207,  224 
Catheter — 

Examination  by,  217-218,  219,  220,  223 


332  INDEX. 

Catheter — {continued) 

Inability  to  pass,  153-154 
Catheterisation,  ureter  examined  by,  216-217 
Cavities,  internal  measurement  of,  27 
Centrifugaliser,  227 
Cerebellum,  abscess  in,  64,  66,  67 
Cerebral  abscess — 

Complications  of,  64 

Localisation  of,  66-67 

Pysemic  secondary,  63 

Symptoms  of,  65 
Cerebro-spinal  fluid,  discharge  of,  through  ear,  28S 
Cervical  glandular  enlargement,  273 

Plexus,  involvement   of  nerves  in  malignant  thyroid  disease, 

113 

Spine,  abscesses  of,  268 

Sympathetic,  paralysis  of,  36 
Charcot's  disease,  255,  257 
Cheek- 
Dyspeptic  ulcers  on,  75 

Pain  in,  in  connection  with  antral  suppuration,  49 

Ulceration  of,  causing  closure  of  jaw,  71 
Chest- 
Axillary  glandular  enlargement  due  to  sore  on,  273 

Examination  of,  for  causes  of  dysphagia,  82 

Injuries  to — 

Thoracic  contents,  involving,  294-298 
Wall,  293-294 

Pain  in,  in  upper  dorsal  caries,  265 
Chloroform,  35,  37 
Chylous  ascites,  133 
Cicatricial  adhesions  causing  nasal  obstruction,  42 

Stricture,  intestinal  obstruction  secondary  to,  170 
Cirrhosis  of  liver,  ascites  due  to,  132 
Clavicle,  acute  osteitis  of,  241 
Cleft  palate,  79 
Cocaine,  35,  92 
Colles's  fascia,  233 
Colic,  causes  of  pain  in,  159-161 
Colon.    See  Intestine 
Colour-blindness,  18 

Compression,  brain  injury  from,  284-285 
Concussion  :  of  brain,  284  ;  of  spinal  cord,  314-315 
Condyle,  inner,  glandular  swellings  near,  271 
Condylomata,  characters  of,  201 
Congenital  bands,  causing  intestinal  obstruction,  169 

Hernia,  182;  diagnosed  from  acquired,  184 
Constipation — 

Chronic,  164 

Hernia,  significance  in,  186 

Intestinal    obstruction,    a    symptom    of,    170,    171,    172-173 ; 
diagnosed  from,  168 


INDEX.  333 

Constipation — [coyitiyived) 

Intestinal  strangulation,  in,  i66 

Rectal  diseases,  due  to,  197 
Contused  wounds  of  spinal  cord,  315-316 
Convulsions,  significance  of,  in  brain  abscess,  65-66 
Coughing,  hernial  swelling,  felt  in,  180 
Cranial  cavity,  suppuration  in,  62-69 

Nerves,  affections  of,  in  meningitis,  68-69 
Cremaster  muscle,  hypertrophy  of,  231 
Crepitus,  318 
Cretinism — 

Abdomen,  tumid,  of,  130 

Symptoms  of,  104-105 
Cricoarytenoid  joint,  fixation  by  inflammation,  98 
Cricothyroid  muscle,  paralysis  of  nerve  of,  96 
Cricoid  cartilage,  perichondritis  of,  90 
Crystals  in  urine,  212-213,  224 
Cyrtometer,  26 

Cystic  duct,  obstruction  causing  tumour  of  gall-bladder,  148 
Cystitis — 

Complicating  pyuria  or  haematuria,  224 

Differential  diagnosis  of,  226 

Dysuria  due  to,  210 

Mucus  in  urine  in,  30,  212 

Pyelitis  secondary  to,  225 

Simple,  cause  of,  226 

Urine  of,  213 
Cystoscope.    See  Endoscope 
Cystotomy,  229 
Cysts — 

Bladder,  of,  153 

Blood- 
Abdominal  wall,  in,  135 
Peritoneal  cavity,  in,  141,  142 
Retro-peritoneal,  143 

Breast,  of,  116,  117,  121-122 

Intraperitoneal,  rupture  due  to  blow  on,  299 

Local  protrusions  of  fluid,  249-250 

Morrant  Baker's,  249 

Ovarian,  131,  132,  133;  uterine  swellings  simulating,  154 

Pancreatic,  150 

Renal,  152 

Thyroid,  110-112,  114,  278 


Deafness — 

Causes  of,  54,  61-62 

Differential  diagnosis  as  to  cause  of,  61-62 
Deglutition,  88,  90 

Delirium  in  intracranial  suppuration,  68 
Dermatitis,  malignant,  at  nipple  of  breast,  124 


334  INDEX. 

Diabetes,  29,  30,  209,  211,  212 

Diagnosis,  art  of,  i  ;  aira  of,  2  ;  method,  23  ;  probability  in,  6-9  ; 

by  exclusion,  9  10  ;  importance  of  revision,  1 1  ;  importance  of 

previous  treatment,  16 
Diarrhoea — 

History  of,  in  :  appendicitis,  164  ;  intestinal  disease,  146,  170 

Kectal  diseases,  due  to,  197 
Diphtheria,  47,  90,  99 
Diphtheritic  paralysis,  87 
Discharges,  examination  of,  30 

Diseases,  suggested  classification  for  diagnosis  by  exclusion,  10 
Dislocations,  320-321 
Distension  of  abdomen,  307 
Diuretic  medicines,  211 

Dorsal  spine,  abscess  in  connection  with,  269 
Drowsiness,  65,  69 
Duodenum — 

Liability  to  injury,  303 

Pancreatic  tumour  involving,  1 50-1 51 

Perforation,  situation  of  pain  due  to,  165 

Perforative  peritonitis  secondary  to  ulcer  of,  163,  164 
Dura  mater,  localised  meningitis  of,  69 
Duration  of  disease,  importance  of,  in  diagnosis,  13,  15 
Dysentery,  history  of,  in  intestinal  obstruction,  170 
Dyspepsia,  superficial  glossitis  due  to,  75 
Dysphagia — 

Causes  of,  81,  82,  86-87,  90 
Examination  for — 

External,  81-83  ;  internal,  83-84 
Eontgen  rays,  by,  84  85 
Malignant  thyroid  disease,  in,  113 
Dysphonia,  89,  100 

Dyspnoea,  causes  of,  89-90,  97,  100,  292,  295 
Dysuria,  causes  of,  209-210 


Ear — 

Auricle,  affections  of,  53 

Bleeding  from,  causation  of,  287-288 

Cerebro-spinal  fluid  discharged  from,  288 

Deafness,  causes  of,  54 

Inflammation  of  middle  ear,  48 

Meatus,  discharge  from,  53-54  ;  origin  of  pus  in,  49 

Nose,  association  with  disease  of,  40 

Pain  in,  causes  of,  55 

Physical  examination  of,  55 

Tinnitus,  54-55 
Eczema,  53 
Elbow- 
Effusion  of  blood  into,  250 

Lateral  movement  at,  257 


INDEX.  335 

Elbow — {continued) 

Position  of  bones  in  joint  disease  of,  254 
Electric  battery,  use  of,  in  diagnosis,  27-28 

Oystoscope,  225 
Elephantiasis,  233 
Emphysema,  296 
Empyema — 

Lateral  curvature  of  spine  secondary  to,  261 

Secondary  to  caries  of  dorsal  spine,  268 
Enchondroma  of  testis,  236 
Endoscope,  23,  216,  217,  218,  219,  224,  225,  229 
Enema,  use  of,  in  diagnosis,  36 
Enteritis  simulating  intestinal  obstruction,  167 
Eosinophile  leucocytes,  percentage  in  normal  blood,  33-34 
Epididymis — 

Hydrocele  of,  234 

Swellings  involving,  235 
Epididymitis,  231 
Epigastric  artery,  wound  of,  300 
Epigastrium — 

Gall-stone  colic  referred  to,  194 

Tumour  in,  146 
Epiglottis,  91,  94 
Epiphysis — 

Acute  periostitis  of,  diagnosed  from  inflammation  of  neigh- 
bouring joint,  242 

Inflammation  of,  254 

Separation  of,  319-320 
Epithelioma — 

Bladder,  of,  229 

Diagnosis  from  rodent  carcinoma,  41 

Discharges  in,  30 

Larynx,  of,  100-102 

(Esophagus,  of,  85-86 

Palate,  of,  80 

Secondary,  simulating  abscess,  274 

Tongue,  of,  76  ;  diagnosis  of,  77-78 
Erysipelas,  scrotal  inflammation  due  to,  232 
Erysipelatous  cellulitis  of  leg,  241 
Ether,  use  of,  in  diagnosis,  35 
Ethmoid  bone,  tumours  originating  in,  46 
Ethmoidal  sinus,  nasal  discharge  from  disease  of,  49 
Eucaine,  use  of,  in  diagnosis,  35 
Eustachian  catheter,  27,  59-60 

Tube,  obstruction  of,  54,  57,  59,  60,  61 
Ewing,  cited  32,  33  and  notes 
Examination,  physical,  methods,  2-3,  4-6,  20  seq. 
Excitability,  a  symptom  in  Graves's  disease,  109-110 
Excretions,  examination  of,  29-30 
Exophthalmos,  109-110 
Expectoration,  blood-stained,  85 
Exploratory  operations,  38-39,  307-308 


336  INDEX. 

Eye,  examination  of,  36 
Eyelids,  discolouration  of,  287 

Face— 

Cervical  glandular  enlargement  due  to  sore  on,  272-273 
Wounds  about,  283 
Facial  paralysis :    in  cerebral  abscess,  66-67  ;  through  fracture  of 

petrous  bone,  289 
Faeces,  undigested  fat  in,  30 
Faintness,  in  Addison's  disease,  153 
Fallopian  tube,  enlargement  of,  simulating  :  distension  of  bladder, 

153  ;  uterine  swellings,  154 
False  cord,  94 
Femoral    herniae,    179,    182  ;    diagnosed    from  other   varieties   of 

hernia,  183 
Femur — 

Exostosis  of,  243 

Malignant  tumour  of,  diagnosed  from  inflammatory  swelling, 

244 
Osteitis  of,  condition  of  skin  in,  241 
Sarcoma  of,  239 

Tibia  displaced  on,  in  disease  of  knee,  255 
Tumour  of,  256 
Fibro-adenoma  of  breast,  118,  121 

Fibro-lipomata  simulating  masses  of  enlarged  glands,  272 
Fibromata — 

Laryngeal,  99 
Nasal,  45,  52 

Nasopharynx,  in,  43  ' 

Tongue,  of,  78 
Fibroid  disease  of  breast  diagnosed  from  cancer,  120 
Fibula,  hypertrophy  of,  239 
Fissure,  rectal — 

Diseases  accompanying,  201 
Examination  for,  202-203 
Fistula,  rectal — 

Diseases  accompanying,  201 
Examination  for,  201-202,  203-204 
Fistula,  urinary,  scrotal  swelling  due  to,  233 
Flatus,  passage  of,  diagnostic  value  of,  166 
Fluid— 

Hernial  sac,  in,  185 

Instruments  for  injecting  or  withdrawing,  27 
Vomiting  of,  significance  of,  149 
Withdrawal  of,  method,  37 
Forehead,  pain  in,  from  frontal  suppuration,  49 
Foreign  bodies,  detection  of,  25-26 
Fractures,  bony,  318-320,  effusion  of  blood  into  neighbouring  joint 

from,  250 
Fright,  quantity  of  urine  increased  by,  212 
Frontal  sinus — 

Examination  of,  24 


INDEX.  337 

Frontal  sinus — (continued) 

Nasal  disease  associated  with  disease  of,  40  ;  nasal  discharge 
from  disease  of,  49 

Empyema  of,  51 
Funicular  hernia,  184 


Gait  of  cerebellar  abscess,  67 
Gall-bladder — 

Abdominal  swelling  due  to  disease  of,  L^y 

Catarrhal  inflammation  of,  complicating  gall-stones,  193-194 

Enlarged — 

Characters  of,  147-148 

Kidney  swellings  simulating,  126,  147,  152 

Stone  causing,  189,  198 

Palpation  of,  128 

Perforation  of,  133,  163,  164  ;  situation  of  pain  from,  165 

Suppuration  within,  192-195 

Ulceration  due  to  gall-stones,  192 
Gall-stones — 

Diagnosis  of,  188  seq.  ;  from  carcinoma,  191 

Intestinal  obstruction  due  to,  169 

Pain  due  to,  191-192,  193-194 
Gangrene  complicating  strangulated  hernia,  187 
Gastric  juice,  decrease  of  free  hydrochloric  acid  in,  30 
Gastric  ulcers.    See  Ulceks,  Gasteic 
Genital  organs — 

Enlargement  of  glands  in  groin  due  to  sore  on,  273 

Examination  of,  230-231 
Glanders,  47 

Glossitis,  73  ;  superficial,  75 

Glosso-epiglottic  fossae,  relation  to  disease  of  larynx,  92 
Glosso-labio-laryngeal  paralysis,  Sy,  89 
Glottis,  spasm  of,  90 
Glycosuria,  temporary,  causation  of,  37 
Goitre- 
Inflammation  of,  simulating  malignant  disease,  114 

Parenchymatous,  diagnosis  of,  108-110,  112 

Thyroid  enlargement  due  to,  105 
Gonorrhoea,  47,  222,  226 
Gonorrhoea!  epididymitis,  235 

rheumatism,  joints  infected  by,  250 
Granulomata  in  larynx,  99 
Grating  of  joints,  257 

Graves's  disease,  105;  diagnosis  of  goitre  of ,  107,  108-110 
Groin — 

Granular  swellings  in,  271,  273 

Inflammatory  swelling  simulating  abscess,  272 

Pain  of  kidney  disease  referred  to,  157 
Gumma — 

Closure  of  jaws  due  to,  71 

Dyspnoea  due  to,  90 

Y 


3  3  8  INDEX. 

Gumma — {continued) 

Sarcoma  of  palate  simulating,  8o 
Tongue  enlargement  due  to,  73-74 


Habits  of  life- 
Importance  of  considering,  in  diagnosis,  17 

Influence  of,  in  causation  of  intestinal  obstruction,  169 
Hsematemesis,  146 
Hsematocele,  32,  234-235 

Haematoma,  formation  of,  due  to  fracture  of  posterior  fossa,  287 
Hsematuria — 

Bladder,  evidence  of  blood  derived  from,  223-224,  226-228 

Inflammation,  simple,  due  to,  225-226 

Intermittent,  229 

Kidney,  relation  to,  224-225,  226-228,  306 

Origin  of,  221-222,  225-229 

Painless,  causation  of,  228 

Pelvic  abscess  causing,  225 

Uraemia,  in,  207 

Ureter,  origin  in,  224-225 

Urethra,  evidence  of  blood  derived  from,  222-223 
Haemoglobin,  estimation  of,  34 
Hemophilia,  5-6,  18,  51,  251 
Haemoptysis,  signification  of,  298 
Haemorrhage  — 

Fracture  of  skull,  due  to,  287 

Fractured  limbs,  with,  318-319 

Internal,  32,  299,  307 

Nasal,  51 

Peritoneal  cavity,  into,  141 

Kectal,  198-199 

Spinal  cord,  around,  317 

Uterine,  146 
Haemorrhoids — 

Painless  haemorrhage  due  to,  199 

Protrusion  at  anus,  200 
Head — 

Cervical  glandular  enlargement  due  to  sore  on,  272-273 

Injuries  to — 

Bones  of  cranium,  285-289 

Soft  parts  outside  skull,  283  ;  inside,  284-285 

Eetraction  of,  in  meningitis,  69 
Headache — 

Intracranial  suppuration,  with,  64-65,  67 

Meningitis,  in  68 

Sphenoidal  suppuration,  with,  49 

Tumours  in  upper  nasal  regions,  with,  46 
Heart — 

Disease  of — 

Nasal  haemorrhage  evidencing,  51 
Pain  referred  to  left  breast  from,  116 


INDEX.  339 

Heart — {continued) 

Shifting  of  position  of,  296 

Wound  of,  295,  297 
Hepatic  duct,  distension  of,  from  stone  in  bile-duct,  190 
Heredity,  18-19 
Hernia — 

Age  influence  on  incidence  of,  169 

Anatomical  varieties,  diagnosis  of  different,  183-184 

Congenital,  182;  diagnosed  from  acquired,  184 

Contents  of,  diagnosis  of  condition  of,  184-187 

Diagnosis  of — 

Continuity  with  viscera  in  abdomen,  178-180 
Impulse  on  coughing,  180-181 
Eeducibility,  by,  181-182 
Eesonance  on  percussion,  181,  185 

Diaphragmatic,  simulating  pneumothorax,  297 

Femoral,  179,  182;  diagnosed  from  other  varieties,  183 

History,  182-183 

Inguinal,  182,  183 

Intestine,  of.     See  under  INTESTINE 

Obstructed,  186 

Obturator,  182  ;  diagnosed  from  femoral,  183 

Omentum,  of.     See  under  Omentum 

Strangulated,  181;  strangulated  diaphragmatic,  176 

Translucency  in  infants,  234 

Umbilical,  135,  179 

Ventral,  135 
Hip- 
Caries  of,  pyuria  in  connection  with,  222 

Congenital  dislocation,  238 

Disease — 

Knee  weakness  due  to  application  of  weight  extension  to, 

257 
Pain  referred  to  knee  in,  247 
Trochanter,  displacement  of,  255 

Distension  of  joint  simulating  aneurism,  277 

Effusion  into,  248 

Local  protrusion  of  fluid  in  joint,  250 

Pain  referred  from  spine  to,  247,  265 

Position  of  bones  in  disease  of  joint,  254 

Pus  in,  251-252 

Synovial  membrane,  swelling  of,  253 

Tuberculosis  of,  254 
History  of  disease,  value  of,  in  diagnosis,  2-3,  16-19,  170  ;  method 

of  ascertaining,  12-16 
Hoarseness — 

Cause  of,  93 

Injury  of  hyoid  bone  and  larynx,  in,  292 

Significance  of  persistent,  loi 
Humerus — 

Dislocation  of,  320-321 

Effusion  of  blood  into  elbow,  fracture  caused  by,  250 


340  INDEX. 

Humerus — {continued^ 

Osteitis  of,  condition  of  skin  in,  241 

Surgical  neck  of,  fracture  of,  319 
Hydatid  cyst — 

Cellular  tissue  close  to  bladder,  of,  153 

Urine,  in,  213 
Hydrocele,  24,  178,  182-183,  234,  236 
Hydronephrosis,  133,  151-152,  215 
Hydrophobia,  87 
Hyoid  bone,  injury  to,  292 
Hypertrophic  rhinitis,  44 
Hypochondrium — 

Tumour  in,  146,  148 

Tympanites  in,  149 
Hypogastrium,  pain  in,  223 
Hypoglossal  nerve — 

Damage  of,  by  fracture  of  posterior  fossa,  289 

Paralysis  of,  74 
Hysteria — 

Aphonia  due  to,  89 

Closure  of  jaw  in,  72 

Dysphagia  from,  81,  87 

Movements  restricted  in,  256 

Urine  passed  in,  211 


Idiocy,  cretinism  simulating,  105 
Iliac  fossa — 

Appendicitis  due  to  blow  on  right,  299 

Injury  to,  303 

Palpation  of,  in  diagnosing  hernia,  182 
Ilium — 

Fractures  of,  309 

Liability  of  lower  end  to  injury,  303 

Malignant  tumour  diagnosed  from  inflammatory  swelling,  244 
Infantile  paralysis,  atrophy  of  bone  in,  238 
Infants,  significance  of  discharge  of  pus  from  nose  in,  47 
Inguinal  glands,  enlargement  of,  237 
Inguinal  hernia — 

Femoral  hernia  diagnosed  from,  183 

Scrotum,  descending  into,  182 
Injuries,    examination  and  diagnosis  of  injuries  in  general,   281- 

282 
Insensibility  in  brain  injuries,  284-285 
Insomnia,  207 

Inspection  in  diagnosis,  20-21 
Instruments —  ' 

Bacteria  introduced  by  means  of,  213-214 

Bougies,  84,  223 

Catheter,  223 

Cystoscope.     See  ENDOSCOPE 

Diagnosis,  used  in,  23-29 


INDEX.  34- 

Instruments — {continued) 

Endoscope,  216,  224,  229  ;  Kelly's,  217,  225 
Harm  inflicted  by,  28-29 
(Esophagoscope,  83 
Speculum,  229 
Urethroscope,  220,  223 
Interarj  tenoid  fold,  94 
Internal  ear,  deafness  due  to  disease  of,  61-62 

Jugular  vein,  thrombosis  of,  68 
Intestines — 

Bruising  of,  304 

Colic  of,  cause  of,  160 

Distension  of,  130,  154-155 

Gall-stone  impacted  in,  diagnosis  of,  194 

Hernia  containing — 

Diagnosis  of,  181,  185 
Obstruction  caused  by,  175 
Strangulation,  symptoms  of,  186-187 
Injury  to,  evidence  of,  303,  308 
Large — 

Abscess  connected  with  disease  of,  143 
Carcinoma  of,  137 
Distension  of,  154-155 
Gall-bladder,  enlarged,  relation  to,  147-148 
Percussion  of  dilated,  129 
Eenal  swelling,  relation  to,  152 
Situation  and  relations  of,  27 
Transverse  colon — 
Carcinoma  of,  139 
Malignant  disease  of,  137 
Pancreatic  cysts  pressing  on    151 
Obstruction  of — 

Age,  influence  of,  in  diagnosing  cause,  7-8 
Complications  of,  167-168 
Differential  diagnosis,  167-168 
Diseases  simulating,  167 

Nature  and  seat  of  obstruction,  determination  of,  168-177 
Perforative  peritonitis  secondary  to,  164 
Peritonitis  complicating,  134 
Symptoms  of,  170-173 
Pain  from  disease  of,  157 
Perforation  of,  137,  164 
Small,  strangulation  of — 

Pain  in  umbilicus  from,  157 
Vomiting  caused  by,  170 
Strangulated — 

Acute,  159-166 

Peritonitis  in  connection  with,  161 
Tuberculous  ulceration  of,  173 
Tumours  of,  uterine  swellings  simulating,  154 
Intra-thoracic  growths,  dysphagia  due  to,  82 
Intra-uterine  amputations,  238 


342  INDEX. 

Intussusception,  diagnosis  and  symptoms  of,  168-169,  172-173,  174, 

199 
Iodide  of  potassium  in  diagnosis,  36,  78 
Ischiorectal  abscess,  196,  270 


Jaundice — 

Emaciation  due  to,  191 

Significance  of,  146,  164 

Stone  in  bile-duct,  caused  by,  190 

Tumour  of  gall-bladder  associated  with,  148 
Jaws,  closure  of,  causes,  70-72 
Joints — 

Dislocations  of,  321 

Distension  by  fluid  diagnosed  from  swelling  of  synovial  mem- 
brane, 253 

Examination  for  diseases  of,  246 

Fractures  extending  into,  319 

Inflammation  of — 

Characteristic  symptom  of,  247-248 
Diagnosis  between  eflfusion  of  blood  and,  257 

Injuries  to,  25,  321 

Movements  of  diseased — 
Grating,  257 

Eestriction  of  movement,  255-256 
Unnatural  mobility,  256-259 

Muscles  surrounding  diseased,  255 

Pain  in,  causation  of,  247 

Protrusions  of  fluid,  249 

Kelative  position  of  bones,  254-255 

Stiffness  in,  from  aneurisms,  279 

Swellings  near,  254 ;  within,  248-253  ;  synovial  membrane  of, 
253-254 


Kelly's  endoscope,  217,  225 
Kidney — 

Calculus  in.     See  Calculus,  Kenal 

Colic,  causes  of,  159,  160 

Congenital  absence  of,  151 

Disease  of,  indications  of,  51,  88,  126,  146 

Enlargement  of,  151 -152,  224;  causes,  227-228;  diagnosis  of 
nature  of,  215-216  ;  diagnosed  from  enlargement  of  gall- 
bladder, 126 

Epithelium  in  urine,  213 

Excreting  power,  indications  of,  212 

Exploratory  operations  on,  215-216 

Inflammation,  simple,  of,  225-226 

Multiple  cystic  disease  of,  urine  of,  211 

New  growth  in,  228 
»     Pain  from  disease  of,  situation  of,  157 


INDEX.  343 

Kidney — (continued) 

Palpation  of,  128 

Pelvis  of,  stone  in,  228 

Physical  examination  of,  215 

Pyuria  or  hsematuria  derived  from,  224-225 

Ketro-peritoneal  :    swellings  involving,   143 ;    fluid   collections 
originating  in,  305 

Kupture  of,  306 

Sarcoma  of,  haematuria  caused  by,  221-222 

Suppurative  conditions  causing  fixity  to  surrounding  parts,  215 

Tuberculous — 

Diagnosed  from  hydronephrosis,  215 
Pyuria  and  haematuria  due  to,  226-227 
Urine  in,  213 

Tumour  of.    See  Tumoues,  Renal 
Knee — 

Effusion  into,   249,    253  ;    secondary  to  loose  cartilage,   252 
effusion  of  blood  from  fracture  of  tibia,  250 

Examination  of,  246 

Jerk.     See  Tendon  Reflex 

Lateral  movement,  257 

Loose  cartilage  in,  252 

Pain  referred  from  hip  to,  247 

Position  of  bones  in  disease  of,  254 
Kyphosis,  259-240 


Labium,  pain  of  kidney  disease  referred  to,  157 

Lactic  acid,  contents  of  stomach,  in,  30 

Laryngeal  nerve,  paralysis :  of  superior,  89,  96-97  ;  of  inferior,  97 

Lai-yngitis — 

Dyspnoea  due  to,  90 

Mucous  membrane  of  larynx,  appearance  of,  93 

Symptoms  of,  90 

Typhoid  fever,  in  course  of,  88 

Tuberculous,  88,  96 
Laryngoscope,  23,  82-83,  9^ 
Larynx — 

Anaesthesia  of  upper  part,  97 

Displacement  of,  in  thyroid  tumour,  in 

Dysphagia,  connection  with,  82-83 

Foreign  bodies  in,  98-99 

Granulomata  in,  99 

History  of  disease  of,  88-89 

Injuries  to,  291-292 

Innocent  new  growths  in,  99-100 

Malignant  disease  of,  100-102 

Nerve  supply  to,  paralysis  of,  96-97 

ffidemaof,  73 

Physical  examination  of,  35,  91-93  ;  of  mucous  membrane,  93-« 
94 ;  of  submucous  tissues,  94-96  ;  of  vocal  cords,  96-98  ; 
for  strictures  within  the  cavity,  98-102 


344  INDEX. 

Larynx — {continued) 

Secondary  disease  of,  88-89,  9^ 

Symptoms  of  disease  of,  89-90 

Thyroid  swelling  simulating  disease  of,  107 
Lateral  sinus,  infective  thrombosis  of — 

Complications  of,  64 

Perforation  of  petrous  bone  in  otitis  media  causing,  66 

Symptoms  of,  68 
Left  ventricle,  hypertrophy  of,  vs^ith  renal  disease,  206-207 
Leg,  paralysis  of,  in  cerebral  abscess,  66-67 
Lenses,  simple  magnifying,  23 
Leprosy,  diagnosis  of  case  of,  17 
Leucocytes,  varieties  of,  in  blood,  32-34 
Leucocythsemia,  51 
Leucocytosis,  31-32 

Leukaemia,  diagnosis  from  lymphadenoma,  33-34 
Ligaments,  rupture  of,  321 
Light,  transmitted,  use  of,  in  diagnosis,  24-26 
Limbs — 

Enlargement  of  glands  in  groin  due  to  sore  on  lower,  273 

Fractures  of,  318-319 
Lipomata — 

Breast  enlargement  due  to,  118 

Hernia,  simulating,  179 

Scrotal,  233 
Lips,  dyspeptic  ulcers  on, 
Lithotrite,  27 
Liver — 

Abdominal  swellings  due  to  disease  of,  137 

Cirrhosis  of,  ascites  due  to,  132 

Crush  of,  evidence  of,  303 

Dilatation  due  to  stone  in  bile-duct,  190 

Hydatid  cyst  of,  145 

Jaundice  evidencing  disease  of,  146 

Lardaceous,  145 

Nasal  haemorrhage  indicating  disease  of,  51 

Pain  from,  referred  to  :  shoulder,  157  ;  right  breast,  116 

Pain  in,  from  perforation  of  gall-badder,  164 

Palpation  of,  128 

Percussion  of,  128-129,  133,  304 

Suppuration  in,  192 

Tumour  of — 

Characters  of,  146-147 
Gall-bladder  diagnosed  from,  148 
Renal  cysts  simulating,  152 
Locomotor  ataxy,  239,  245,  255 
Loin — 

Dulness,  significance  of,  152 

Palpation  of,  128 
Lordosis,  260 
Lumbar  glands,  enlargements  of,  143,  237,  271 


INDEX.  345 

Lung — 

Blood  in,  298 

Injury  to,  295-296,  298 

Solidification  of,  298 
Lupus  of  nose,  41 

Lymphadenoma,  diagnosis  from  leukaemia,  33-34 
Lymphadenomatous  glands,  295 
Lymphangiomata,  78 
Lymphatic  glands,  enlargement  of — 

Abscess  simulating,  272,  274 

Causation,  272-273 

Inflammation  with  infective  thrombosis  of  lateral  sinus,  68 

Malignant,  273-274 

Multiplicity  of  swellings,  271-272 

Situation,  usual,  of,  271 

Syphilitic,  273-275 

Thyroid  malignant  disease,  with,  113 

Tuberculous,  diagnosed  from  syphilitic,  275 
Lymphocytes,  percentage  in  normal  blood,  33 
Lymphosarcoma,  glands  of,  284 


Mackenzie-Davidson  apparatus,  26 

Macrodactyly,  238 

Macroglossia,  73 

Mast  cells,  33 

Mastoid  antrum,  inflammation  involving,  54-55 

Mastoid  region,  examination  of,  55-56 

Meatus — 

Abscess  in,  55 

Discharge  from,  53-54 

Examination  of,  56 

Obstruction  in,  causing  deafness,  54 

Pus  in,  origin  of,  49 
Meckel's  diverticulum,  169 
Mediastinal  glands,  enlargement  of,  271 

Mediastinum,  septic  inflammation  spreading  from  neck  to,  292 
Melaena,  305 
Membrana  tympani — 

Deafness  connected  with,  54 

Examination  of,  56-58 

Haemorrhage  from  rupture  of,  288 

Inflammation  of,  57 

Perforation  of,  57,  58 
Meningitis — 

Complications  of,  64 

Symptoms  of,  68-69 
Menstruation,  pain  due  to  hernia  of  ovary  during,  185 
Mensuration — 

Employment  in  diagnosis,  22 

Instruments  for  aiding,  26-27 


34^  INDEX. 

Mercury,  in  diagnosis,  36 

Mesentery,  uterine  swellings  simulating  tumours  of,  154 

Micro-organisms,  detection  of,  34 

Micrococcus  urese,  214 

Microscope,  urine  examined  by,  213 

Micturition — 

Frequency  of,  209,  214,  223 

Painful,  209-210,  221-222 
Middle  ear — 

Deafness  due  to  interference  with  mechanism  of,  54 

Discharge  from,  53 

Inflammation  of,  48,  55 

Inflation  of,  as  a  means  of  diagnosis,  58-61 

Suppurative  disease,  intracranial  complications  of,  62-65 

Ulceration  of,  55 
Mikulicz,  cited,  34 
Mollities  ossium,  239 
Morphia,  diagnosis  hindered  by,  37 
Morrant  Baker's  cysts,  249 
Motions,  blood  in,  305 
Mouth— 

Affections  of,  causing  glandular  enlargement  of  neck,  273 

Examination  for  causes  of  dysphagia,  82-83 

Floor  of,  inflammatory  swellings  of,  74 

Inability  to  open,  70-72 
Mucus — 

Eectal  discharge  of,  172-173,  199 

Urine,  in,  212,  214,  234 
Muscles — 

Lower  jaw,  of,  inflammation  of,  70 

Neck,  rigidity  of,  in  meningitis,  69 

Eupture  of,  321-322 

Spasm  of,  dysphagia  due  to,  81  ;  around  inflamed  joint,  255  ; 
spasmodic  movements  due  to  cerebral  irritation,  285 

Tremor  of,  207 

Twitchings  of,  significance  in  cerebral  abscess,  65 

Wasting  of,  255 

Wound  of,  322 
Muscular  system,  dysphagia  associated  with  disease  of,  87 
Myxoedema — 

Enlargement  of  tongue  in,  73 

Symptoms  of,  104-105 
Myelocytes,  33,  34 


N^VI,  78 

Nasal  cavity,  diseases  of — 

Atrophic  rhinitis,  41,  48,  52 
Hypertrophic  rhinitis,  44 
Malignant  tumours,  45-46 
Polypi,  44-45 
Smell  from,  48,  52 


INDEX.  347 

Nasal  cavity,  diseases  of — {continued) 
Symptoms  of — 

Discharge  of:  mucus,  46-47  ;  pus,  47-51  ;  blood,  51-52 
Obstruction:  bilateral,  42-43;  unilateral,  43-46 
Csmell,  perversion  of,  52 
Nasopharynx — 

Examination  of,  40 
Tumours  of,  42,  239 
Neck — 

Examination  of,  for  cause  of  dysphagia,  81-82 

Glandular  swellings  in,  271,  273,  274 

Injuries  to,  290-292 

Multiple  neuro-fibromata  of,  272 

Tuberculous  glands,  pus  in,  274 

Tumours  of — 

Bruit  simulating  that  of  aneurism,  278 
Pulsating,  277 
Necrosis — 

Bone,  of,  53,  240,  245 
Cartilage,  of,  90,  91 
Thyroid  swelling,  simulating,  107 
Nephritis,  urine  of,  30,  211,  212 
Nerve  deafness,  54,  61-62 
Nerves — 

Cranial,  symptoms  of  injury  to,  288-289 
Injuries  to,  322-323 

Paralysis  of,  in  intrathoracic  aneurism,  280 
Spinal,  involvement  of,  in  spinal  diseases,  264-265 
Nervous  system — 

Dysphagia  associated  with  diseases  of,  87 
Joint  disease  secondary  to  disease  of  central,  255 
Symptoms  of  disease  of,  52 
Nervousness,  quantity  of  urine  increased  by,  212 
Neutl:ophife  leucocytes,  percentage  in  normal  blood,  33 
Nose — 

Accessory  sinus,  disease  of,  45 

Bleeding  from,  from  fracture  of  anterior  fossa,  288 

Bones  and  cartilages,  disease  of,  41 

Examination  of,  40 

External  nose,  40-42 

Interior.     See  Nasal  Cavity 

Septum.     See  Septum  Nasi 


Obesity,  129-130 

Obturator  foramen,  fracture  of,  309 

Hernia,  182  ;  diagnosed  from  femoral,  183 
Occipital  pain  in  upper  cervical  caries,  265 
Occupation,  importance  of  considering,  in  diagnosis,  17 
CEdema — 

Breast,  of,  118 


34^  INDEX. 

OEdema — (_contuiued) 

Larynx,  of — 

Area  affected,  94 

Causes,  94  ;  due  to  Bright's  disease,  88,  94 

Dyspnoea  due  to,  90 

Swelling  of,  95 

Scrotum,  of,  232 

Tendency  to,  with  renal  disease,  206 
(Esophagoscope,  use  of,  83 
(Esophagus — 

Affections  of,  causing  glandular  swelling  of  neck,  273 

Carcinoma  of,  89 

Congenital  pouch  of,  86-87 

Dysphagia,  connection  with,  81,  82,  83 

Examination  of,  83-84  ;  by  Rontgen  rays,  84-85 

Malignant  growth  of,  thyroid  swelling  diagnosed  from,  107-10S 

Stricture  of,  evidence  of,  84  85,  86 
Omental  hernia — 

Diagnosis  of,  185 

Impulse  on  coughing,  absence  of,  181 

Strangulation  of,  187 
Operative  procedures,  37-39 
Ophthalmoscope,  23 
Opium,  diagnosis  hindered  by,  37 
Optic  neuritis — 

Brain  abscess,  in,  65,  66 

Meningitis,  in,  68 
Orbit,  injury  to  nerve  supply  of,  289 
Osteitis  deformans,  240-241,  260 
Osteomalacia,  239 

Otitis  media.     See  Mii:>dle  Eae,  Disease  of 
Ovary — 

Cyst  of,  131,  132,  133 

Hernia  of,  185 

Enlargement     of,    simulating  :    distension    of    bladder,    153 ; 
uterine  swellings,  154 

Malignant  disease  of,  complicated  by  ascites,  134 
Oxalate  of  lime  in  urine,  213 


Paget's  disease,  124 

Pain- 
Loose  cartilage  on  knee-joint,  from,  252 
Referred,  11 5- 116,  247,  264-265,  314 
Starting,  in  joint  disease,  247-248 

Palate,  diseases  of,  79-80 

Palpation — 

Abdomen,  of,  128 
Bladder,  of,  with  sound.  217 
Instruments  for  aiding,  26-27 
Methods  of  performing,  21-22,  35 
Thorax,  of,  296 


INDEX.  349 

Palpation — ( continued ) 

Urethra,  of,  219-220 
Pancreas — 

Abdominal  section  in  diagnosing  disease  of  38 

Cancer  of  head  of,  causing  obstruction  of  bile-duct,  190 

Duct  of,  obstruction  of,  150 

Inflammation,  chronic,  causing  obstruction  of  bile-duct,  190 

Tumours  of,  characters  of,  1 50-1 51 
Papillomata — 

Bladder,  of,  hsematuria  caused  by,  221-222,  229 

Laryngeal,  99-100 

Tongue,  of,  epithelioma  simulating,  78 
Paraplegia,  266 
Paralysis — 

G-losso-labio-laryngeal,  87,  89 

Haemorrhage  around  spinal  cord  with,  317 

Limbs,  of,  due  to  spinal  diseases,  266,  316 

Symptoms  of,  in  cerebral  abscess,  65-67 
Patella,  fracture  of,  319 ;  frequent  occurrence  of,  explained,  239 
Pectoral  muscle,  adhesion  to,  in  carcinoma  of  breast,  123 
Pelvic  organs,  inflammatory  disease  of,  causing  :   perforative  peri- 
tonitis, 163  ;  intestinal  obstruction,  169 
Pelvis — 

Abscess  of,  pain  due  to  perforation,  165 

Injuries  to,  303,  309-312 

Swellings  of  abdominal  wall  due  to  disease  of,  136-137 

Tumour  of,  256 
Penis,  pain  in,  223 

Percussion,  employment  of,  22,  128-129,  297 
Pericarditis,  septic  absorption  with,  240 
Pericardium — 

Effusion  into,  82 

Septic  inflammation  spreading  from  neck  to,  292 

Wound  of,  295,  297 
Perichondritis — 

Cricoid  cartilage,  of,  90 

Physical  symptoms  of,  91 

Thyroid  swelling,  simulating,  107 
Perinephritic  abscess,  215,  228 
Perineum — 

Abscess  in,  220,  232-233 

Enlargement  of  glands  in  groin  due  to  sore  on,  273 

Examination  of,  for  cause  of  pyuria  or  hematuria,  223 

Pain  in,  223 

Palpation  in  connection  with  disease  of  urethra,  220 

Spinal  abscess  perforating,  270 
Periostitis — 

Acute  infective,  240 

Epiphysis,  affecting,  242 

Long  bone,  of,  inflammation  of  soft  parts  simulating,  241 

Eib,  of,  pain  from,  referred  to  breast,  115 

Scurvy  rickets  simulating  acute,  241 


350  INDEX. 

Peritoneal  cavity — 

Inflammations  extending  through  the   abdominal   wall  from, 

137-138 

Lesser, 'fluid  collections  in,  142-143;  tumour  of,  142,  150 

Opening  of,  through  wound  of  abdominal  wall,  300 

Swellings  in — 

Blood-cysts,  141 

Fluid  collections,  37,  130-133,  140-141,  304-305,  307 
Pus  collections,  141-142 
Peritoneal  fluid — 

Herniae,  in,  184 

Pathological  varieties  of,  132-133 
Peritoneum — 

Chronic  inflammation  of,  ascites  due  to,  132-133 

Hernial  contents  descending  into  unobliterated  funicular  pro- 
cess, 182 

Parietal,  new  growth  in,  138 

Eenal  swelling,  relation  to,  152 

Retro-peritoneal  swellings.    See  that  title 
Peritonitis — 

Abdominal  distension  evidencing,  130,  304 

History  of,  in  intestinal  obstruction,  170 

Intestinal  obstruction,  simulating  and  complicating,  134,  167 

Pain  in,  157-158,  161-162 

Perforated  gall-bladder  causing,  192 

Perforative,  7,  159,  161-165,  192 

Strangulation  of  intestine  secondary  to,  166 

Tuberculous,  137,  140-14 1 
Petrous  bone — 

Fracture  of,  289 

Perforation  of,  63,  66 
Phalanges,  congenitally  enlarged,  238 
Pharynx — 

Affections  of,  causing  glandular  swellings  of  neck,  273 

Blood  from  fracture  of  anterior  base  of  skull  in,  288 

Congenital  pouch  of,  86 

Dysphagia,  connection  with,  81,  82-83 

Examination  of,  for  causes  of  dysphagia,  82-82 

Implication  of,  in  laryngeal  diseases,  92,  100 

Malignant  growth  of  thyroid  swelling  diagnosed  from,  107-108 

Nasal  discharge  into,  49 

Post-pharyngeal  abscesses  connected  with  spinal  caries,  268 

Ulceration  of,  causing  :  closure  of  jaw,  71  ;  oedema  of  larynx, 

94 
Phonation,  88-39 

Phosphates  in  urine,  212,  213,  214 
Piles,  201-202 

Pilocarpine,  use  of,  in  diagnosis,  36 
Pleura — 

Blood  in,  298 

Distension  of,  with  air,  296 

Inflammation  of,  pain  fi'om,  referred  to  breast,  115 


INDEX.  351 

Pleura — (continued') 
Injury  of,  294 

Septic  inflammation  spreading  from  neck  to,  292 
Pleural  eif  usion,  82,  297 
Pleurisy — 

Lateral  curvature  of  spine  secondary  to,  261 
Septic  absorption,  with,  240 
Pneumothorax,  296,  297,  298 
Politzerisation,  59-60 
Politzer's  bag,  27 
Polypi- 
Ear,  of,  haemorrhage  from,  288 
Intussusception  diagnosed  from,  174 
Membrana  tympani,  of,  58 
Nasal,  42-46 

Obstruction  of  bowel  due  to,  173 
Painless  haemorrhage  from  rectum  due  to,  198-199 
Protrusion  at  anus  due  to,  199-200 
Popliteal  aneurism,  pain  down  leg  in,  280 

Space,  glanudular  swellings  in,  271 
Posterior  fossa — 

Fracture  of,  287,  289 
Meningitis  of,  69 
Pregnancy,  enlargement  of  breast  in,  117 
Processus  vaginalis,  184 
Prolapse,  protrusion  at  anus  from,  199-200 
Prostate — 

Enlarged — 

Kidneys  destroyed  by,  208 
Micturition,  frequent,  with,  209 
Senile,  219 

Stream  of  urine,  influence  on  character  of,  2 10-2 11 
Examination  of ,  218-219 
Inflammation  of — 
Characters,  218 
Dysuria  due  to,  210 
Pyuria  originating  in,  223 
Psoas  abscess,  179,  180,  181 
Puberty,  breast  enlargement  at,  117 

Pulmonary  symptoms  in  infective  thrombosis  of  lateral  sinus,  68 
Pulsation — 

Aneurismal,  276-279 
Brain  abscess,  in,  65  ;  brain  injuries,  284 
Pulse — 

Graves's  disease,  in,  109-110 

Infective  thrombosis  of  lateral  sinus,  in,  68 

Injuries  to  abdominal  wall,  in,  300 

Internal  haemorrhage,  in,  307 

Intestinal  strangulation,  in,  166 

Meningitis,  of,  68 

Peritonitis,  of,  163 

Radial  pulses,  inequality  of,  280 


352  INDEX. 

Pulse — {continued) 

Eupture  of  bladder,  in,  311 
Septic  absorption,  in,  240 

Pupils,  pin-point,  207 

Purgatives,  use  of,  in  diagnosis,  36 

Pus- 
Effusion  into  joints,  251-252 
Liver  dulness  due  to  collection  of,  305 
Nipple  of  breast,  discharged  from.  124 
Nose,  discharged  from,  47-51 
Rectal  discbarge  of,  199 
Urine,  in.     See  Pyuria 

Pyaemia,  34,  250 

Pysemic  secondary  abscess  of  brain,  63 

Pyelitis,  simple,  225-226 

Pylorus,  149 

Pyonephrosis, — enlargement  of  kidney  due  to,  215 

Pyo-salpinx,  32 

Pyuria — 

Bacturia  causing,  214 

Bladder,  evidence  of  pus  derived  from,  223-224. 

Calculus  causing,  226-228 

Caries  of  hip  or  spine,  with,  222 

Inflammation,  simple,  due  to,  222.  225-226 

Kidney,  origin  in,  224-225 

New  growth  causing,  228-229 

Pelvic  abscess  causing,  225 

Tuberculous  disease,  226-228 

Ureter,  pus  derived  from,  224-225 

Urethra,  pus  derived  from,  222-223 


Quinine,  use  of,  in  diagnosis,  36 


Ranula,  effect  on  tongue,  74 
Rectum — 

Capacity  of,  determination  of,  27 

Carcinomatous  stricture,  pain  accompanying,  196 

Congenital  malformations.  205 

Constipation  due  to  diseases  of,  197 

Diarrhoea  due  to  disease  of,  197 

Examination  of,  35  ;  importance  of  making,  200-201  ;  examina- 
tion for  different  diseases,  201-205 

Haemorrhage  from,  importance  of  age  in  diagnosing  cause  of,  7 

Sheath  of,  blood  cysts  in,  136 

Stricture  of,  201,  204-205 

Suppuration  around,  pain  from,  197 

Symptoms  of  disease  of — 

Blood,  discharge  of,  198-199 
Motions,  size  and  shape  of,  198 
Mucus,  discharge  of,  199 


INDEX.  353 

Rectum — {continned) 

Symptoms  of  disease  of — [conflniipd) 

Normal  functions,  mode  of  performing,  1 97-1 98 

Pain,  196-197 

Protrusion  at  the  anus,  199-200 

Pus,  discharge  of,  199 

Questions  elucidating,  195 

Wounds  of,  312 
Recurrent  laryngeal  nerve,  involvement  of  in  :  malignant  thyroid 

disease,  113;  inflamed  goitre,  114 
Reflectors,  23 
Reflexes,  effect  of  fracture-dislocation  of  spine  on.  316-317  ;  tendon. 

266,  267 
"  Renal  bankruptcy,"  20S 
Renal  disease.     See  Kidney 
Respiration,  88,  89-90;  in  brain  injuries,  284;  panting.  207.  208; 

sighing,  in  cerebral  abscess.  65-66 
Retinitis  with  renal  disease,  207 
Retroperitoneal  cellular  tissue,  tumours  of,  154 

fluid  collections,  305 
Retro-uterine  hcTmatocele,  141 
Rheumatism — 

Acute,  effusion  into  joints  due  to,  250 

Inflammatory  affections  of  bone  with,  240 
Rheumatoid  arthritis,  239,  250,  252,  254,  255,  257,  260,  2G4,  277 
Rhinoscopv,  40,  44. 
Ribs- 
Cartilages,  apparent  breast  swelling  due  to  locally  prominent,  118 

Fracture  of,  293-294,  303 
Rickets — 

Abdomen,  tumid,  of,  130 

Bone  softening  due  to.  239 

Cretinism  simulating,  105 
Rigors,  65-68 

Rima  glottidis,  blocking  of,  291 
Rinne's  test,  62 
Rodent  carcinoma,  41 
Rontgen  rays — 

Prolonged  application,  effect  of,  29 

Use  of,  in  diagnosis,  24-26,  84-85,  215.  227,  244,  262,  270,  294, 
310,  320 
Round  ligament,  183 


Sageo-iliac  joint,  fracture  of,  309 

Sacro-sciatic  foramen,  spinal  abscesses  perforating,  270 

Salicylate  of  soda,  use  of,  in  diagnosis,  36 

Saliva — 

Diminution  of,  29 

Glairy,  85 
Salivary  calculus,  effect  on  tongue,  74 

duct,  obstruction  of,  29 

Z 


354  INDEX. 

Sarcinse  in  vomited  contents  of  stomach,  30 
Sarcomata — 

Abdominal  wall,  in,  136 

Aneurism,  simulating,  277 

Bone,  of,  239,  244 

Larynx,  of,  100 

Myeloid,  diagnosed  from  periosteal,  243-244 

Nasal,  52 

Nasopharyngeal,  43 

Palate,  of,  80 

Eenal,  221-222 

Retro-peritoneal,  origin  of,  147 

Testis,  of,  231,  235 
Scalp,  contusions  of,  diagnosed  from  depressed  fracture.  283 
Scars,  93-94 
Sclerosis  of  bone,  239 
Scoliosis  of  spine,  261,  262-263 
Scrotum — 

Abscess,  localised,  of,  233 

Cellular  tissue,  localised  swellings  in,  233 

Chronic  hypertrophy  of,  233 

Co-existence  of  diseases  in,  237 

Distension  with  air,  181,  232  ;  with  blood,  232 

Elephantiasis,  233 

Examination  of,  230-231 

loflammation  of,  causes  of,  232-233 

(Edema  of,  232 

Spermatic  cord,  183  ;  examination  of,  230-231 

Testis.     See  that  name 

Tunica  vaginalis.     See  that  name 
Scurvy  rickets  simulating  acuDe  periostitis.  241-242 
Secretions,  examination  of,  29-30 
Sepsis — 

Leucocytosis  in.  32 

Symptoms  of,  192,  240 

Strangulated  hernia,  in,  187 

Uraemia,  in.  208-209 
Septic  matter,  introduction  of,  with  instruments,  29 
Septum  of  nose — 

Destruction  of,  41 

Disease  of,  43-44 

Displacement  of,  43 

Tertiary  syphilitic  disease  of,  48 
Sex- 
Importance  of  con.sidering,  in  diagnosis,  7 

Intestinal  obstruction,  influence  in  causation  of,  169 

Perforative  x^eritonitis,  influence  in  causation  of.  163 
Shoulder — 

Investigation  for  disease  of.  246 

Pain  from  liver  referred  to,  157 
Sigmoid  flexure — 

Stricture  of,  174 


INDEX.  355 

Sigmoid  flexure — (continued') 

Volvulus  of,  causing  intestinal  obstruction,  170 

Sinuses  {sec  also  Anteum,  Feontal,  Sphenoidal,  &c.),  discharges 
from,  30 

Skin- 
Abdominal,  swellings  in,  135 

Breast  of,  affections  of,  124  ;  involvement  in  breast  inflamma- 
tions, 118-119,  122-123 
Osteitis,  condition  in,  241 
Pigmentation  of,  in  Addison's  disease,  153 
Strangulated  hernia,  condition  in,  187 

Thyroid  gland,  condition  with  diminished,  104  ;  involvement  in 
tumours  of,  113 

Skull- 
Base,  fracture  of,  286-289 
Enlargement  of  bones  of,  240 
Vault,  fracture  of,  285-286 

Smell- 
Diseases  of  nasal  cavity,  from,  48,  52 
Perverted  sense  of ,  52 

Sound,  examination  by — 
Bladder,  217,  224 
Prostate,  218,  219 
Ureter,  216-217 
Urethra,  220 

Spasm  of  muscles  surrounding  inflamed  joint,  255 

Speculum,  use  of,  in  diagnosis,  23,  229 

Spermatic  cord,  183  ;  examination  of,  230-231  ;  causes  of  enlarge- 
ment, 231  ;  hydrocele  of,  234  ;  hypertrophy,  180  ;  swellings  of, 

233-234 
Spermatozoa  in  hydrocele  of  epididymis,  234 
Sphenoid  bone,  tumours  originating  in,  46 
Sphenoidal  sinus,  nasal  discharge  from  disease  of,  49 
Sphymograph,  27 
Spina  bifida,  238,  267 
Spinal  cord — 

Concussion  of  314-315 
Contused  wounds  of,  315-316 
Cystitis,  conditions  favouring,  226 
Haemorrhage  around,  317 
Incised  wounds,  315 

Pressure  upon,  causes  and  symptoms,  264-267 
Shape  of,  examination  of,  258  259 
Vertebral  column,  injuries  to,  313  314 
Spine- 
Abscesses  of.     See  Abscess,  Spinal 
Caries  of — 

Abdominal  pain  due  to,  156 

Abscess  in  connection  with,  267-268,  270 

Curvature  of  spine  due  to,  26,  260-261 

Injury,  due  to,  314 

Method  of  detecting,  22,  264,  270 


35^  INDEX. 

Spine — {cont'nmed) 

Caries  of — [conthvued) 

Pain  referred  to  breasts  from,  ii6 
Pyuria  in  connection  with,  222 
Tuberculous,  260,  264-265 

Cervical,  caries  of,  269 

Curvature  of,  259-261,  265 

Dorsal.     See  Dorsal  Spine 

Fracture  of,  266,  313,  315-316  ;  fracture  dislocation,  313,  316- 
.  317 

Injury  of,  simple  pyelitis  due  to,  225 

Kyphosis,  259-260 

Lateral  curvature  of,  118,  261-262 

Local  swellings  with  diseases  of,  267 

Lordosis  of,  260 

Lumbar  or  sacral  pain  referred  to,  247 

Movements  of,  methods  of  testing,  263-264 

Nervous  symptoms  with  diseases^of,  264-267 

Peritoneal  abscess  with  disease  of,  143 

Scoliosis,  261  263 
Spleen — 

Abdominal  swelling  due  to  disease  of,  137 

Crush  of,  evidence  of,  303 

Hypertrophy  of,  145 

Malarious,  tap  on,  causing  haemorrhage,  299 

Palpation  of,  128 

Percussion  of,  128-129 

Tumour  of,  125-126,  146,  148 
Staphylococci  in  urine,  214 

Staphylococcus  pyogenes  aureus,  in  pysemic  blood,  34 
Starting  pain  in  joint  disease,  247-248 
Sternum — 

Dulness  on  percussion,  possible  significance  of,  279 

Fracture  of,  294 
Stomach — 

Abdominal  swelling  due  to  disease  of,  137 

Ache,  persistent,  possible  significance  of,  265 

Blood  from  fracture  of  anterior  fossa  in,  288 

Carcinoma  of,  30,  38 

Dilated — 

Characters  of,  148-149 
Percussion  of,  129 

Indications  of  disease,  126 

Liquid  contents  of,  escape  of,  into  peritoneal  cavity.  304 

Mucous  membrane,  rupture  of,  305 

Pain,  situation  of,  157,  164  ;  referred  to  left  breast,  116 

Perforation  of,  situation  of  pain  from,  164 

Position  of:  due  to  pancreatic  cyst,  150  ;  and  relations,  deter- 
mination of.  27 

Ulcer  of,  142,  163,  164 

Vomited  contents  of,  abnormal  substances  in,  30 
Stone.     See  Calculi 


INDEX.  357 

strangulated  hernia,  diagnosis  of,  186-187 
Strangulation  of  small  intestine,  vomiting  caused  by,  170 
Streptococci — 

Blood,  in,  34 

Urine,  in,  214 
Stricture — 

Intestines,     of,     blood    and    mucus     discharged    from    anus 
in,  173 

Eectum,  of,  201,  204-205 

Urethra,  of,  219 
Subcutaneous  tissue,  abdominal,  swellings  in,  135 
Sugar,  test  for,  213 
Superior  maxilla,  atrophy  due  to  tumour  of  naso-pharynx,  239 

meatus,  origin  of  pus  in,  49 
Suppuration  diagnosed  from  haemorrhage,  32 
Supra-renal  gland,  diseases  of,  152-153 

Sympathetic  nerve,  involvement  in  malignant  thyroid  disease,  113 
Synovia,  248-250,  321 
Syphilis— 

Bone,  of,  41,  240,  242 

Congenital,  pus  discharged  from  nose  in,  47 

Glandular  enlargement  attending,  273 

Joints  infected  by,  250 

Laryngeal — 

Granulomata  due  to,  99 
Symptoms  of,  94,  95 

Nipple,  sore  at,  124 

Palate,  diseases  of,  due  to,  79 

Synovial  membrane  of  joints  thickened  in,  253 

Tertiary — 

Chronic  ulcer  in  case  of,  5 
Nasal  signs  of,  48 

Testis,  of,  235,  237 

Tongue,  affections  of,  73  74,  75.  76 

Tubercle  diagnosed  from,  275 
Syringing  of  meatus,  56 


Teeth — 

Bad,  causing  :  superficial  glossitis,  75  ;  inflammatory  swellings 
of  palate,  80 

Inflammations  of,  causing  inability  to  open  mouth,  70 
Temperature  in — 

Abdominal  abscess,  141-142  ;  abdominal  injury,  307 

Brain  abscess,  65 

Colic,  161 

Concussion  of  brain,  284 

Gall-stones,  191 

Infective  thrombosis  of  lateral  sinus,  68 

Intra-cranial  suppuration,  in,  65 

Meningitis,  68 

Peritonitis,  163 


35^  INDEX. 

Temperature  in — (c-ontlnued) 

Pus  within  a  joint,  251 

Rupture  of  bladder,  311 

Septic  absorption,  240 

Ursemia,  207-208 
Temporal  bone,  63,  64 

fossa?,  71 
Temporo-maxillary  articulation,  71 
Temporo-sphenoidal  lobe,  abscess  in,  64,  66,  67 
Tenderness  in  colic,  160 

Tendon  reflexes,  diminution  of,  267  ;  exaggeration  of,  266 
Tendons,  wounds  of,  322 
Testis— 

Abscess  of,  233 

Examination  of,  230-232,  235 

Malignant  disease  of,  236 

Pain  of  kidney  disease  referred  to,  157 

Sarcoma  of  231,  236 

Tubercle  of,  235 

Tumours  of,  234,  236  ;  diagnosed  from  fluid  swellings,  237 
Tetanus,  72,  81,  d)"]^  160 
Thermometer,  27 
Thigh,  pain  referred  to  from  :  kidney  disease,  157  ;  spinal  diseases 

265,  270 
Thirst  in  uraemia,  208 
Thorax — 

Abdominal  swelling  due  to  disease  of,  137 

Aneurism,  intrathoracic,  signs  of,  280 

Dulness  on  percussion,  possible  significance  of,  279 

Injuries  of — 

Contents,  to,  294-298 
Scrotal  swelling  due  to,  232 
Throat,  diseases  of,  association  with  nasal  disease,  40 
Thrombosis,  infective,  of  lateral  sinus,  64,  68 
Thyroid  gland — 

Adenomata  of,  110-112 

Chronic  primary  inflammation,  109 

Cysts  of,  110-112 

Diminution  in  size,  diseases  causing,  104-105 

Malignant  disease  of,  38,  no,  11 2-1 14 

Swellings  of — 

Diagnosis  from  other  neck  swellings,  106-108;  differential 

diagnosis,  108-114 
Diseases  causing,  105 
Thyrotomy,  99,  102 
Tibia- 
Acute  osteitis  of,  241 

Congenital  absence  of,  239 

Displacement  of,  in  knee  disease,  255 

Effusion  of  blood  into  knee  from  fracture  of,  250 

Enlargement  of,  240 
Tinnitus,  causation  of,  54-55 


INDEX.  359 

Tongue — 

Atrophy  of,  74 

Disease  of,  relation  to  disease  of  larynx,  92 

Epithelioma  of,  76  ;  diagnosis  of,  77-78 

Glossitis,  73,  75 

Macroglossia,  73 

Myxoedema,  in,  73 

Protrusion  of,  causes  of  difficulty  in,  74 

Sublingual  swellings,  74 

Syphilitic  disease  of,  73-74,  75,  76 

Tuberculous  ulcers  of,  76 

Ulcers  of,  76,  94 
Tonsil,  pus  from  suppurating,  presenting  as  post-pharyngeal  abscess, 

268 
Trachea — 

Displacement  of,  in  thyroid  tumour,  1 1 1 

Examination  of,  102-103 

Kupture  of,  291 
Tracheotomy,  99,  292 
Transillumination,  50 
Traumatism,  51 

Tremulousness  in  Graves's  disease,  109,  no 
Trichinosis,  blood  in,  34 

Trochanter,  displacement  of,  in  hip  disease,  255 
Tuberculin,  use  of,  in  diagnosis,  36 
Tuberculous  disease — 

Bacillus  of,  detection  of,  227 

Bladder,  of,  226-227 

Bone,  of,  240,  242,  245,  257 

Breast,  of,  diagnosed  from  cancer,  119  120 

Calculus  of  bladder  simulating,  210 

Diagnosis  of,  30,  36 

Hereditary  transmission  of,  18 

Joints  infected  by,  250,  251,  255 

Kidneys,  of,  226-227 

Knee,  of,  254 

Laryngeal — 

Complicating  other  diseases,  88 

Mucous  membrane,  appearance  of,  93 

Sputum,  examination  of,  96 

Symptoms  of,  83,  90,  95  : 

Lesions  of,  bacteria  in  discharges  from,  30 

Palate,  tuberculous  swellings  of,  79 

Peritoneum,  of,  137,  140-141 

Prostate,  of,  218 

Pyelitis,  urine  of,  30 

Spinal  caries,  260,  264-265 

Suprarenal  gland,  of,  153 

Synovial  membrane  thickened  by,  253 

Syphilitic  glands  diagnosed  from  those  of,  275 

Testis,  of,   diagnosis  of,  236  ;  between  syphilitic  disease  and, 
235  ;  malignant  disease  simulating,  237 


360  INDEX. 

Tuberculous  disease — [continued) 

Ulcers  of  tongue,  76 
Tumours — 

Abdominal  (Peritoneal  cavity,  in,  see  that  name),  133-134,   136, 

139 

Bone,  of,  diagnosed  from    inflammatory  affections,    242-245  ; 
atrophy  of  bone  caused  by,  238-239 

Breast,  of  duct,  124 

Bruit,  iDresenting,  278 

Carcinoma.     See  that  title 

Closure  of  jaws  due  to,  71,  72 

Diagnosis  of,  8-9 

Epigastric,  135-136 

Groups  of,  272 

Hereditary  transmission  of,  19 

Hydronephrotic,  125 

Innocent,  simulating  cured  aneurism,  278 

Joint  movements  arrested  by,  256 

Lipomata.     See  that  name 

Lobulated,  simulating  masses  of  enlarged  glands,  272 

Malignant — 

Laryngeal,  90,  91 
Nasal,  45-46 
Puncture  of,  35-38 
Thyroid  gland,  of,  113 

Nasal,  41-42,  45-46,  52 

Neck,  of,  closure  of  jaw  due  to,  71,  72 

(Esophagus,  of,  ^tj 

Origin,  investigation  of,  15 

Ovarian,  origin  of  swelling,  125 

Palate,  of,  80 

Papilloma.     See  that  title 

Pedunculated,  protrusion  at  anus,  199-200 

Pharyngeal,  87 

Pulsating,  276-277 

Renal — 

Characters,  1 51-153 

Chronic  abscess  of  loin  simulating,  145-146 

Gall-bladder,  enlarged,  simulating,  147 

Sarcoma.    See  that  title 

Spinal,  267 

Splenic,  125,  126,  146,  148 

Testis,  of,  236 

Thyroid  gland,  of.     See  Thyeoid  Gland— Swellings 
Tunica  albuginea,  236 
Tunica  vaginalis — 

Congenital  hernia,  condition  in,  184 

Local  dilatation  of,  234 

Swellings  of,  234,  235 
Tuning-fork,  use  of,  in  diagnosis,  54,  61-62 
Tympanites,  in  left  hypochondrium,  149 
Tympanum,  perforation  of,  63,  67 


INDEX.  361 


Typhoid  fever — 

Laryngitis  in  course  of,  88 

Perforative  peritonitis  secondary  to,  164 

Thyroid  inflammation  secondary  to,  109 


Ulcees— 

Articular  cartilage,  of,  248 

Cheek,  of,  71 

Discharges  from,  30 

Duodenal,  perforative  peritonitis  due  to,  163 

Gastric,  142,  163,  164 

Intestinal  obstruction  due  to,  170 

Laryngeal,  92,  94  ;  in  laryngitis.  93 

Malignant,  diagnosed  from  carcinoma,  41 

Middle  ear,  in,  55 

Palate,  of,  79 

Strangulated  hernia,  complicating,  187 

Tongue,  of,  73,  75-78 
Umbilical  cord,  thickening  of,  simulating  hernial  neck,  180 

hernia,  omentum  in,  185 
Umbilicus — 

Gall-stone  colic  referred  to,  194 

Inflammatory  swellings  in  region  of,  137,  138 

Pain  from  intestinal  disease  referred  to,  157,  166 
Urates  in  urine,  212 
Ursemia,  29,  207-208 
Urea — 

Decrease  of,  30,  126 

Urine,  in,  212,  214 
Ureter — 

Examination  of,  216-217 

Pyuria  and  haematuria  derived  from,  224-225 

Eetro -peritoneal  fluid  derived  from,  305 

Stone  in,  detection  of,  216,  224,  228 
Urethra — 

Bacteria  introduced  into  urine  from,  214 

Examination  of,  219-220 

Dysuria  due  to  inflammatory  condition  of,  209-210 

Prostatic,  obstruction  to,  219 

Pyuria  and  haematuria  derived  from,  222-223 

Eupture  of,  311-312 

Stricture  of,  209,  210,  211,  219 
Urethroscope,  220,  223 
Uric  acid  iu  urine,  213 
Urinary  organs.    See  also  Kidneys,  Blaeder,  &c. 

Diminution  in  normal  excreting  power — 
Signs  and  symptoms  of,  206-207 
Uraemia,  types  of,  207-208 

Micturition,  frequent,  209,   214,  223  ;  painful,    209-210,    221- 
222 

2   A 


362  INDEX. 

Urine — 

Abnormal  constituents  of,  30,  213 

Albumen  in,  225 

Alterations  in,  diagnostic  value  of,  146 

Amount  passed,  significance  of,  177.  21 1-2 12 

Blood  in.     Sec  H.5:matueia 

Casts  in,  224,  225 

Colour  of,  212 

Crystals  in,  224 

Deposits  in,  212-213 

Diabetic,  29,  30 

Diminution  of,  29,  126 

Extravasation  of,  143,  232-233,  310-312 

Mucus  in,  30,  212,  224 

Peritoneal  cavity,  in,  133 

Pus  in.     See  Pyueta 

Eetro-peritoneal  collections  of,  143,  305 

Specific  gravity  of.  212 

Stream  of,  alterations  in  character,  210-21 1 

Uraemia,  in.  207,  208 

Urea  in,  212 
Uterus — 

Blood  and  pus  in  urine  derived  from,  223 

Fibroid  tumour  of,  133,  145 

Internal  measurement  of,  27 

Swellings  of,  153-154 


Vagina— 

Abnormal  fistulous  communication  v^rith,  205 

Blood  and  pus  in  urine  derived  from,  223 

Heematocele  of,  234-235 

Hydrocele  of,  234 
Varicocele,  diagnosed  from  hernia,  181-182 
Varicose  saphenous  vein,  diagnosed  from  hernia.  181-182 
Vas  deferens,  235 

Vein,  dilated,  impulse  on  coughing,  181 
Venous  swellings  diagnosed  from  hernia.  182 
Ventral  hernia,  135-136 
Vertebral  column,  injuries  to,  313-314 
Vesical  ends  of  ureters,  inspection  of,  224-225 

inflammation,  indications  of,  224 

orifice,  examination  of,  216 
Vesiculffi  seminales,  examination  of,  218 
Villous  growth  in  urine,  30,  213 
Vocal  cords — ■ 

Carcinoma  on,  101-102 

Displacement  of,  96 

Infiltration  by  inflammatory  products  or  new  growth.  98 

Larynx — 

Inflamed,  effect  of,  93 


INDEX.  363 

Vocal  cords  —{cuntlnned) 

Larynx — ( cant  i  meed) 

CEdema  of,  bounded  by,  94-95 

Paralysis  of,  83,  ^6.  89,  96-97 
Voice,  effect  of  paralysis  of  superior  laryngeal  nerve  on,  96 
Vomiting — 

Abdominal  injury,  in,  305  ;  abdominal  pain,  with,  159 

Addison's  disease,  in,  153 

Blood,  of,  126 

Hernia,  significance  in,  186 

Intestinal  obstruction,  a  symptom  in,  167-172 

Intestinal  strangulation,  in,  166 

Intra-cranial  suppuration,  with,  65,  67,  68 

Morning,  in  uraemia,  208 

Stages  of,  in  passing  gall-stone,  194 

Uraemia,  in,  207 


Wasting  in  uraemia,  208 

Watson,  cited,  go,  note 

Weber's  test,  61-62 

Wisdom-tooth,  carious,  pain  in  ear  from,  55 

Women,  blood  and  pus  in  urine  of.  223 

Wrist-joint,  position  of  bones  in  inflamed,  254 


NOTE  SUBJECT  INDEX 
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SUBJECT  INDEX. 


Gould's  Medical  Dictionaries, 
Morris'  Anatomy,  =  =  = 
Compends  for  Students,  - 


Pages  12,  13 
Page  4 
Page  27 


SUBJECT.  TA&M 

Alimentary  Canal  (see  Svir- 

gery)   24 

Anatomy 7 

Anesthetics    18,  19 

Autopsies  (see  Pathology)  20 

Bacteriology    8 

Bandaging  (see  Svirgery)  .  .  24 

Blood,  Examination  of . . .  8 

Brain 8 

Bright's  Disease 26 

Chemistry.     Physics    ....  9 

Children,  Diseases  of 11 

Climatology 19 

Clinical   Charts 25 

Compends 27 

Consumption  (see  Lungs)  .  16 

Cyclopedia  of  Medicine ...  13 

Dentistry 11 

Diabetes  (see  Urin.  Organs)  25 

Diagnosis 11 

Diagrams  (see  Anatomy) .  8 

Dictionaries,   Cyclopedias .  12 

Diet  and  Food 13 

Disinfection 16 

Dissectors 7 

Ear    14 

Electricity    14 

Embryology 7 

Emergencies 24 

Eye   14 

Fever* 15 

Food 13 

Formularies 21 

Gynecology    15 

Hay  Fever 25 

Heart    15 

Histology 15 

Hydrotherapy 19 

Hygiene    16 

Hypnotism 8 

Insanity 8 

Intestines 23 

Latin,  Medical  (see  Phar- 
macy)    21 

Life  Insurance 19 

Lungs 16 

Massage    17 

Materia  Medica 17 

Mechanotherapy 17 


eXTBJECT.  PAaB 

Medical  Jurisprudence ....  18 

Mental  Therapeutics 8 

Microscopy 18 

Milk    8,10 

Miscellaneous 18 

Nervous  Diseases 19 

Nose    25 

Nursing 20 

Obstetrics 20 

Ophthalmology 14 

Organotherapy    18 

Osteology  (see  Anatomy)  .  7 

Pathology 20 

Pharmacy 21 

Phj^sical  Diagnosis 11 

Physical  Training 17 

Physiology 22 

Pneumotherapy 19 

Poisons  (see  Toxicology)  .  .  18 

Practice  of  Medicine 22 

Prescription  Books  (Phar- 
macy)      21 

Refraction  (see  Eye) 14 

Rest    19 

Sanitary  Science »g  16 

Serum-Therapy 17 

Skin 23 

Spectacles  (see  Eye) 14 

Spine    (see    Nervous    Dis- 
eases)      19 

Stomach „ 23 

Students'   Compends 27 

Surgery  and  Surgical  Dis- 
eases      24 

Technological  Books .....  9 

Temperature  Charts 25 

Therapeutics    17 

Throat    25 

Toxicology 18 

Tumors  (see  Surgery) ....  24 

U.  S.  Pharmacopoeia 22 

L^rinary  Organs 25 

Urine 25 

Venereal  Diseases 26 

Veterinary  Medicine 26 

Visiting  Lists,  Physicians'. 
{Send  for  Circvlar.) 

Water  Analysis 16 

Women,   Diseases  of. ... .  15 


Self-Examination  tor  Medical  Students.  3500  Questions  on 
Medical  Subjects,  with  References  to  Standard  Works  in  which 
the  correct  replies  will  be  found.  Together  with  Questions 
from  Stats  Examining  Boards.     8d  Ed.     Paper  Corer,  10  ©ta. 


SUBJECT  CATALOGUE  OP  MEDICAL  BOOKS.         7 

SPECIAL  5N0TE. — The  prices  givea  in  this  catalogue  are 
net ;  no  discount  can  be  allowed  retail  purchasers  under  any  con- 
sideration. This  rule  has  been  established  in  order  that  everyone 
will  be  treated  alike,  a  general  reduction  in  former  prices  having 
been  made  to  meet  previous  retail  discounts.  Upon  receipt  of 
the  advertised  price  any  book  will  be  forwarded  by  mail  or 
express,  aU  charges  prepaid. 


ANATOMY.     EMBRYOLOGY. 

MORRIS.  Text-Book  of  Anatomy.  Third  Revised  and  Enlarged 
Edition.  846  Illustrations,  267  of  which  are  printed  in  colors. 
Thumb  Index  in  Each  Copy.  Cloth,  $6.00 ;  Leather,  $7.00 

"The  ever-growing  popularity  of  the  book  with  teachers  and 
students  is  an  index  of  its  value." — Medical  Record,  New  York. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.     2d  Edition,  Enlarged.     337  lUus.     Cloth,  §4.50 

DAVISON.  Mammalian  Anatomy.  With  Special  Reference 
to  the  Cat.     108  Illustrations.  S1.50 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Anatomy  in  its 
Application  to  Medicine  and  Surgery.  With  499  very  hand- 
som.e  full-page  Illustrations  Engraved  from  Original  Drawings 
mad«  by  special  Artists  from  dissections  prepared  for  the  pur- 
pose.    Three  vols.     By  Subscription  only. 

Half  Morocco  or  Sheep,  $30.00;  Half  Russia,  $33.00 

GORDINIER.     Anatomy  of  the  Central  Nervous  System.     With 
271  Illustrations,  many  of  which  are  original.       Cloth,  S6.00 
HEATH.     Practical  Anatomy.    9th  Edition.    321  Illus.       $4.25 
HOLD  EN.     Anatomy.    A  Manual  of  Dissections.    Revised  by  A. 
Hewhon,  m.»..  Demonstrator  of  Anatomy,  Jefferson  Medical 
College,  Philadelphia.     320  handsome  Illustrations.     7th  Ed. 
In  two  compact  12mo  volumes.     850  pages.    Large  New  Type. 
Vol.  I.  Scalp— Face— Orbit— Neck— Throat— Thorax— Up- 
per Extremity.  $1.60 
Vol.  II.  Abdomen — Perineum — Lower  Extremity — Brain — 
Eye — Ear — Mammary  Gland — Scrotum — Testes. 

$1.50 
HOLD  EN.  Human  Osteology,  Comprising  a  Description  of  the 
Bones,  with  Colored  Delineations  of  the  Attachments  of  the 
Muscles.  The  General  and  Microscopical  Structure  of  Bone 
and  its  Development.  With  Lithographic  Plates  and  numer- 
ous Illustrations.     8th  Edition.  $5.25 

HOLDEN.     Landmarks,  Medical  and  Surgical.    4th  Ed.  .76 

HUGHES  AND  KEITH.  Dissections.  With  527  Colored  Plates 
and  other  Illustrations.     In  three  parts. 

I,  Upper  and  Lower  Extremity.  $3.00 

II,  Abdomen— Thorax.  $3.00 

III,  Head— Neck— Central  Nervous  System.  $3.00 

LAZARUS-BARLOW.     Pathological  Anatomy.     21  Plates  and 

171  other  Illustrations.  $6.60 

McMURRICH.     Embryology,    The  Development  of  the  Human 

Body.     276  Illustrations.  $3.00 


SUBJECT  CATALOGUK 


MARSHALL.  Physiological  Diaerams.  Eleven  Life-Size 
Colored  DiagTaias  (each  aeven  feet  by  three  feet  seven  inches). 
Deucned  for  Demonstrfttion  before  the  Class. 

In  Sheets,  Unmounted,  $40.00;  Backed  with  Muslin  and 
Mounted  on  Rollers,  $60.00;  Ditto,  Spring  Rollers,  in  hand- 
some Walnut  Wall  Map  Case,  $100.00;  Single  Plates — Sheets, 
$5.00;  Mounted,  $7.50.  Explanatory  Key,  .50.  Purchaser 
mutt  pay  freight  cftarges. 

MINOT.  Laboratory  Text-Book  of  Embryology.  218  Illustra- 
tions. $4.50 

POTTER.  Compend  of  Anatomy,  Including  Visceral  Anatomy. 
7th  Edition,  Revised  and  Enlarged.  Numerous  Tables,  16 
Plates  and  138  other  Illustrations.       $1.00;  Interleaved,  SI. 25 

TOMES.     Dental  Anatomy.     6th  Edition.  In  Press. 

WILSON.     Anatomy,    11th  Edition.    429  Illus.,  26  Plates.    $5.00 

YUTZY.  Guide  to  the  Dissection  of  the  Human  Body.  Based 
on  Morris'  Anatomy.  Paper  Cover,  .25 

BACTERIOLOGY. 

CONN.     Agricultural    Bacteriology.      Including    the    Study    of 

Bacteria  as  relating    to  Agriciilture,    Soil,   Dairy  and    Food 

Products,  Sewage,  Domestic  Animals,  etc.  Illustrated.  $2.50 
CONK.     Bacteria    in    Milk    and    Its    Products.     Designed    for 

Students  of  Dairying,  Boards  of  Health,  Bacteriologists,  etc. 

Illustrated.  $1.25 

EMERY.     Bacteriological  Diagnosis.     2  Colored  Plates  and  32 

other  Illustrations.  $1.50 

HEWLETT.     Manual  of  Bacteriology.    75  Illustrations.    Second 

Edition,  Revised  and  Enlarged.  $4.00 

HEWLETT.     Serum-Therapy.      Bacteriological    Therapeutics 

and  Vaccines.     Illustrated.  S1.75 

SMITH.     Laboratory  Exercises  in  Bacteriology.     A  Handbook 

for  Students.     Illustrated.  $1.50 

WILLIAMS.  Bacteriology.  A  Manual  for  Students.  99  Illus- 
trations.    3d  Edition,  Revised.  $1.50 

BLOOD,  Examination  of. 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood,  with  Reference  to  Diagnosis.  Six 
Colored  Plates  and  48  other  lUus.       Cloth,  $5.00 ;  Sheep,  $6.00 

BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases.) 

BARR.     Mental  Defectives.     Illustrated.  In  Press. 

BLACKBURN.     A  Manual  of  Autopsies.     Designed  for  the  Use 

of  Hospitals  for  the  Insane.     Illustrated.  $1.25 

CHASE.     General  Paresis.     Illustrated.  $1.75 

DERCUM.     Mental  Therapeutics.  Rest,  Suggestion.    See  Cohen, 

Physiologic  Therapeutics,  page  17. 
60RDINIER.     The  Gross  and  Minute  Anatomy  of  the  Central 

Nervous  System.     With  full-page  and  other  Illua.         $6.00 


MEDICAL  BOOKS. 


IRELAND,     The  Mental  Affections  of  Children.     2d  Ed.     $4.00 
LEWIS    (BEVAN).     Mental     Diseases.      A    Text-Book    having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.    26 
Lithographic  Plates  end  other  Illustrations.     2d  Ed.      17.00 
MANN.     Manual  of  Psychological  Medicine.  $3.00 

PERSHING.      Diagnosis  of  Nervous  and  Mental  Disease.     Illus- 
trated. $1.25 
REGIS.     Mental  Medicine.     By  H.  M.  Bannister,  m.d.    $2.00 
STEARNS.     Mental  Diseases.     With  a  Digest  of  Laws  Relating 
to  Care  of  Insane.    Illustrated.         Cloth,  $2.75;  Sheep,  $3.25 
TUKE.     Dictionary    of    Psychological    Medicine.     Giving    the 
Definition    of    Terms   and    the    Symptoms,    Pathology,    and 
Treatment  of  Mental  Disorders.     Two  volumes.              $10.00 
WOOD,  H.  C.     Brain  and  Overwork,  .40 


CHEMISTRY  AND   TECHNOLOGY. 

Special  Catalogue  of  Chemical  Books  sent  free  upon  application. 

ALLEN.  Commercial  Organic  Analysis.  A  Treatise  on  the 
Modes  of  Assaying  the  Various  Organic  Chemicals  and  Prod- 
ucts Employed  in  the  Arts,  Manufactures,  Medicine,  etc., 
with  Concise  Methods  for  the  Detection  of  Impurities,  Adul- 
terations, etc.     8vo. 

Vol.  I.     Alcohols,  Neutral  Alcoholic  Derivatives,  etc.,  Ethers 
Vegetable  Acids,  Starch,  Sugars,  etc.     3d  Edition.     $4.50 
Vol.  II,  Part  I.     Fixed  Oils  and  Fats,  Glycerol,  Explosives, 
etc.     3d  Edition.  $3.60 

Vol.  II,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants, 
Benxenes,  Naphthalenes  and  Derivatives,  Creosote,  Phenols, 
etc.     3d  Edition.  $3.50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors, 
etc.     3d  Edition.  In  Press. 

Vol.  Ill,  Part  I.  Tannins,  Dyes,  and  Coloring  Matters.  3d 
Edition,  Enlarged   and   Rewritten.      Illustrated.  $4.50 

Vol.  Ill,  Part  II.  The  Amines.  Hydrazines  and  Derivatives, 
Pyridine  Bases.  The  Antipyretics,  etc.  Vegetable  Alka- 
loids, Tea,  Coffee,  Cocoa,  etc.  8vo  2d  Edition.  $4.50 
Vol.  Ill,  Part  III.  Vegetable  Alkaloids,  Non-Basic  Vegetable 
Bitter  Principles.  Animal  Bases,  Animal  Acids,  Cyanogen 
Compounds,  etc.     2d  Edition,  8vo.  $4.50 

Vol.  IV.  The  Proteids  and  Albuminous  Principles.  2d 
Edition.  $4.50 

BAILEY  AND  CADY.     Qualitative  Chemical  Analysis.       $1.25 

BARTLEY.  Medical  and  Pharmaceutical  Chemistry.  A  Text- 
Book  for  Medical,  Dental,  and  Pharmaceutical  Students.  With 
Illustrations,  Glossary,  and  Complete  Index.     5th  Ed.     $3.00 

BARTLEY.  CUnical  Chemistry.  The  Examination  of  Feces, 
Saliva,  Gastric  Juice,  Milk,  and  Urine.    New  Edition.   In  Press. 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experi- 
ments.    9th  Ed.,  Revised.     284  Engravings.  $6.00 

BUNGE.  Physiologic  and  Pathologic  Chemistry.  From  the 
Fourth  German  Enlarged  Edition.  $3.00 

CALDWELL.  Elements  of  Qualitative  and  Quantitative  Chem- 
ical Analysis.     3d  Edition,  Revised.  $1.00 


10  SUBJECT  CATALOGUE. 

CAMERON.     Soap  and  Candles.     54  Illustrations.  $2.00 

CLOWES  AND  COLEMAN.  Quantitative  Analysis.  6th  Edi- 
tion.    125  Illustrations.  $3.50 

COBLENTZ.     Volumetric  Analysis,     Illuatrated.  $1.25 

CONGDON.  Laboratory  Instructions  in  Chemistry.  With 
Numerous  Tables  and  56  Illustrations.  $1.00 

GARDNER.  The  Brewer,  Distiller,  and  Wine  Manufacturer. 
Illuatrated.  $1.50 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of 
Matter.     350  Illustrations.  $4.50 

GROVES  AND  THORP.     Chemical  Technology.     The  Applica- 
tion of  Chemiatry  to  the  Arts  and  Manufactures. 
Vol.  I.  Fuel  and  its  Applications.     607  Illustrations  and  4 
Plates.  Cloth,  $5.00;  i  Mor.,  $6.50 

Vol.11.    Lighting.     Illustrated.        Cloth,  $4.00;  i  Mor.,  $5.50 
Vol.  III.  Gas  Lighting.  Cloth,  $3.50;  i  Mor.,  $4.50 

Vol.  IV.  Electric  Lighting.     Photometry. 

Cloth,  $3.50;  i  Mor.,  $4.60 

HEUSLER.     The  Chemistry  of  the  Terpenes.  $4.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memorand^,  Chemical  and  Micro- 
scopical, for  Laboratory  Use.     6th  h,d.     Illustrated.       $1.00 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic  and 
Organic.     4th  Edition,  Revised.       $1.00;  Interleaved,  SI. 25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  2d  Edition, 
Enlarged.     Illustrated.  $1.25 

LEFFMANN.  Water  Analysis.  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated,     oth  Edition.     Just  Ready.  $1.25 

LEFFMANN.  Structural  Formulae.  Including  180  Structural 
and  Stereo-Chemical  Formulae.     12mo.     Interleaved.       $1.00 

LEFFMAliN  AND  BEAM.  Select  Methods  in  Food  Analysis. 
Illustrated.     2d  Edition.  In  Press. 

MUIR.     Elements  of  Chemistry.  In  Press. 

MUTER.  Practical  and  Analytical  Chemistry.  3d  American 
from  the  Ninth  English  Edition.  Re^/ised  to  meet  the  re- 
quirements of  American  Students.     56  Illustrations.         $1.25 

OETTEL.     Exercises  in  Electro- Chemistry.    Illustrated.  .75 

OETTEL.     Electro-Chemical  Experiments.     Illustrated.  .75 

RICHTER.  Inorganic  Chemistry.  5th  American  from  10th 
German  Edition.  Authorized  translation  by  Edgar  F.  Smith, 
M.A  ,  PH.D.     89  Illustrations  and  a  Colored  Plate.  $1.75 

RICHTER.  Organic  Chemistry.  3d  American  Edition,  trans- 
lated from  the  8th  German  by  Edgar  F.  Smith.  IUus.  2  vols. 
Vol.    I.  Aliphatic  Series.     625  pages.  $3.00 

Vol.  II.  Carbocyclic  Series.     671  pages.  $3.00 

ROCKWOOD.  Chemical  Analysis  for  Students  of  Medicine, 
Dentistry,  and  Pharmacy.     Illustrated.  $1.50 

SMITH.     Electro-Chemical  Analysis.     3d  Ed.  39  IUus.     $1.50 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students 
in  General  Chemistry.    5th  Edition.    Illustrated.  .60 

SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  Quantitative  Estimation  of  Chemical  Substances  by 
MeasTire,  Applied  to  Liquids,  Solids,  and  Gases.  9th  Edition, 
Revised.     112  Illustrations.  Nearly  Ready. 

TRAUBE.     Physico-chemical  Methods.    07  IlliiBtrations.    $1.60 


MEDICAL  BOOKS.  11 


THRESH.     Water  and  Water  Supplies.     3d  Edition.  $2.00 

ULZER    AND    FRAENKEL.        Chemical    Technical    Analysis. 

Translated  by  Fleck.     Illustrated.  $1.26 

WOODY.     Essentials  of  Chemistry  and  Urinalysis.    4th  Edition. 

Illustrated.  S1.60 

***  Special  Catalogue  of  Books  on  Chemistry  fret  upon  application. 

CHILDREN. 

BARR.     Mental  Defectives.     Illustrated.  In  Press. 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     3d  Ed.  $1.00;  Interleaved,  $1.25 

IRELAND.  The  Mental  Affections  of  Children.  Idiocy,  Im- 
becility, Insanity,  etc.     2d  Edition.  $4.00 

POWER.  Surgical  Diseases  of  Children  and  their  Treatment 
by  Modern  Methods.     Illustrated.  $2.50 

STARR,  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  3d  Edition, 
Rewritten  and  Enlarged.     Illiistrated.  S3. 00 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  Sl.OO 

SMITH.     Wasting  Diseases  of  Children.     6th  Edition.  $2.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  2d  Edition, 
Revised  and  Enlarged.     Illustrated.     8vo.  $4.50 

DIAGNOSIS. 

BERRY.    Surgical  Diagnosis.  In  Press. 

DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  Exam- 
ination of  Blood,  with  Reference  to  Diagnosis.  6  Colored 
Plates,  48  other  Illustrations.  Cloth,  $5.00;  Sheep,  $6.00 

DOUGLAS.  Surgical  Diseases  of  Abdomen,  with  Reference  to 
Diagnosis.     20  Full-Page  Plates.     Cloth,  $7.00  ;  Sheep,  $8.00 

EMERY.  Bacteriological  Diagnosis.  2  Colored  Plates  and  32 
other  Illustrations.  $1.50 

MEMMINGER.    Diagnosis  by  the  Urine.    2d  Ed.    24  Illus.    $1.00 

PERSHING,  Diagnosis  of  Nervous  and  Mental  Diseases. 
Illustrated.  $1,25 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  $1.25 

TYSON.  Handbook  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Medicine  in  the  Uni- 
versitj''  of  Pennsylvania.  Illus.  4th  Ed.,  Improved  and  En- 
larged.    With  2  Colored  and  55  other  Illustrations.  $1.60 

DENTISTRY. 

Special  Catalogue  of  Dental  Books  sent  free  upon  application. 
BARRETT.     Dental    Surgery    for    General    Practitioners    and 
Students  of  Medicine  and  Dentistry.     Extraction  of  Teeth, 
et«.     3d  Edition.     Illustrated.  81.00 


12  SUBJECT  CATALOGUE. 

BROOMELL.  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth,  Second  Edition,  Revised  and  Enlarged.  337 
handsome  Illustrations.  Cloth,  $4.50;  Leather,  $5.50 

FILLEBROWN.      Operative  Dentistry.    Illustrated.  $2.25 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition.  Cloth.  $4.00 ;  Sheep,$5.00 

GORGAS.  Questions  and  Answers  for  the  Dental  Student. 
Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental 
Student.     Octavo.  $6.00 

HARRIS.  Principles  and  Practice  of  Dentistrv.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Sur- 
gery, and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S. 
GoROAS,  M.D.,  D.D.s.     1250  lUus.    Cloth,  $6.00 ;  Leather,  $7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the 
Art  and  Practice  of  Dentistry.  6th  Edition,  Revised  and 
Enlarged  by  Ferdinand  J.  S.  Gorqas,  m.d.,  b.d.s. 

Cloth,  $5.00;  Leather,  $6.00 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Gbo.  W.  Warrbn.  691 
Illustrations.  Cloth,  $5.00;  Leather,  $6.00 

SMITH.     Dental  Metallurgy.    2d  Edition.    Illustrated.         $2.00 

TAFT.     Index  of  Dental  Periodical  Literature.  $2.00 

TOMES.  Dental  Anatomy.  263  Illustrations.     6th  Ed.  In  Press. 

TOMES.     Dental  Siu-gery.     4th  Edition.     289  lUus.  $4.00 

WARREN.     Compend  of  Dental  Pathology  and  Dental  Medicine. 

With  a  Chapter  on  Emergencies.    4th  Edition.     Illustrated. 

$1.00;  Interleaved,  $1.25 

WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Illus.  New 
Edition,  Enlarged  and  Revised.  Nearly  Ready. 

WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 

DICTIONARIES.     CYCLOPEDIAS. 

GOULD.  The  Illustrated  Dictionary  of  Medicine,  Biology,  and 
Allied  Sciences.  Being  an  Exhaustive  Lexicon  of  Medicine  and 
those  Sciences  Collateral  to  it:  Biology  (Zoology  and  Botany), 
Chemistry,  Dentistry,  Pharmacology,  Microscopy,  etc.,  with 
many  useful  Tables  and  numerous  fine  Illustrations.  1633 
pages.     Fifth  Edition. 

Sheep  or  Half  Morocco.  $10.00;  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00 
GOULD.  The  Medical  Student's  Dictionary,  nth  Edition.  U- 
lustrated.  Including  those  Words  and  Phrases  generally  used 
in  Medicine,  with  their  Proper  Pronunciation  and  Definition, 
Based  on  Recent  Medical  Literature.  With  Table  of  Epo- 
nymic  Terms  and  Testa  and  Tables  of  the  Bacilli,  Micrococci, 
Mineral  Spring-s,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia, 
Plexuses,  etc.  Eleventh  Edition.  Enlarged  and  illustrated 
with  a  large  number  of  Engravings.     840  pages. 

Half  Morocco,  $2.50 ;  with  Thumb  Index,  $3.00 
Flexible  Leather,  Burnished  Edges,  Thumb  Index,  $3.50 


MEDICAL  BOOKS.  13 


GOULD      The  Pocket  Pronouncing  Medical  Lexicon.     4th  Edi- 
tion.   (30.000  Medical  Words  Pronounced  and  Defined.).  Con- 
taining a  1  the   Words,   their  Definition  and  Pronunciation, 
'that  the  Medical,  Dental,  or  P^^^™f«"*^<l^j  Student  Gener- 
ally Comes  in  Contact  with;   also  Elaborate  Tables  of    Epo- 
nvmic  Terms,  Arceries,  Muscles,  Nerves,  Bacilh,  etc.,  etc.,  a 
DoTe  List  in  both  English  and  Metric  Systems,  etc^,  Arranged 
in  a  Most  Convenient  Form  for  Reference  and  Memonzmg. 
Fourth  Edition,  Revised  and  Enlarged.    838  pages. 
Full  Tirao  Leather,  Gilt  Edges,  $1.00:  Thumb  Index    $1.25 
165,006  Copies  of  Gould's  Dictionaries  have  been  sold. 
TrOTILD    AND    PYLE.     Cyclopedia    of   Practical    Medicine   and 
Surgery     Seventy-two  Special  Contributors.    Illustrated.    One 
VolLne.     A  Concise  Reference  Handbook  of  Medicine,  Sur- 
gery. Obstetrics,  Materia  Medica,  Therapeutics,  and  the  Vari- 
ous Specialties,  with  Particular  Reference  to  Diagnosis  and 
Treatment       Compiled   under   the    Editorial   Supervision   of 
GsoKGrM  GouLD^  M.D. ,  Author  of  "  An  Illustrated  Dictionary 
nf    \tedicine ''   etc  ;   and   Waltbb  L.  Pyi.b,  m  d..  Assistant 
Surgeon  wfl'ls  Eve  Hospital;  formerly  Editor  "International 
Med?ca?Maga2ine,"etc.,and   Seventy-two  Special   Contribu- 
tors     With  many  Illustrations.     Large  Square  8vo,  to  corre- 
■nnnd  with  Gould's  "Illustrated  Dictionary.  -,,Ark 

fS  Sheep  o?  Half  Mor.,  $10.00;  with  Thumb  Index   $11.00 
J  uii  o  c  I.  Half  Russia,  Thumb  Index,  $12.00  net. 

GOULD  AND  PYLE.     Pocket  Cyclopedia  of  Medicine  and  Sur- 

gcry      Based   upon   above   book   and   unitorm   m   size   with 

*"Gould'8  Pocket  Dictionary."  _    „^ 

^"^  Full  Limp  Leather,  Gilt  Edges,  $1.00 

With  Thumb  Index,  $1.25 

PTAPTllS      Dictionary   of   Dentistry.     Including   Definitions   of 

^^Worda  and  Phrases  of  the  CoUateral  Sconces  as  Pertain 

to  the  Art  and  Practice  of  Dentistry-.     6th  Edition.  Revised 

and  Enlarged  by  F.KPXxAxn  J.  S-^oko|s,  m..^i>^.x>.s^^  ^^^^ 

LONGLEY.     Pocket  Medical  Dictionary.  Qoth,  Jo 

TREVES  AND  LANG.     German-English  ^^^^"^^^^^^^^25 

DIET  AND  FOOD. 

ALLEN.  Proteids  and  Albuminous  Principles.  An  a^al^ical 
Study  of  Food  Products.     2d  Edition.  **°^ 

BURNETT.  Foods  and  Dietaries.  A  Manual  of  finical  Diet- 
etics, with  Diet  Lists  for  Various  Diseases,  etc.     3d  Ed.     $1.50 

■n^^^<s.  Dietotheraov.  Food  in  Health  and  Disease.  With 
T^bfes  5  D^etarSrRelative  Value  of  Foods,  etc.  See  Cohen, 
Physiologic  Therapeutics,  page  17. 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated. 

HAIG  Diet  and  Food.  Considered  in  Relation  to  Strength  and 
Power  of  Endurance.     4th  Edition.  x.j 

LEFFMANN.  Select  Methods  in  Food  Analysis.  2d^Ed^t^ion. 
Illustrated. 


U  SUBJECT  CATALOGUK 

EAR  (see  also  Throat  and  Nose). 

BURNETT.     Hearing  and  How  to  Keep  It.     Illustrated.  .40 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynr.  Including 
Anatomy  and  Physiology  of  the  Organ,  together  with  the 
Treatment  of  the  Aflfections  of  the  Nose  and  Pharynx  which 
Conduce  to  Aural  Disease.  128  Illustrations.  2d  Ed.  $5.60 
PRITCHARD.  Diseases  of  the  Ear.  4th  Edition,  Enlarged. 
Many  Illustrations  and  Formxilse.  In  Preaa. 

ELECTRICITY. 

BIGELOW.     Plain  Talks  on  Medical  Electricity  and  Batteries. 

With  a  Therapeutic  Index  and  a  Glossary.     43  Illustrations. 

2d  Edition.  $1.00 

HEDLEY.     Therapeutic  Electricity  and  Practical  Muscle  Testing. 

99  Illustrations.  $2.50 

JACOBY.     Electrotherapy.    2  volumes.    Illustrated.    See  Cohen, 

Physiologic  Therapeutics,  page  17. 

JOKES.     Medical  Electricity.     3d  Edition.     117  lUua.         $3.00 

EYE. 

A  Special  Circular  of  Books  on  the  Eye  sent  free  upon  application. 
DARTER.     Ocular  Therapeutics.     Just  Ready.  $3.00 

DONDERS.     The   Nature   and   Consequences   of   Anomalies   of 

Refraction.  With  Portrait  and  Illus.  Half  Morocco,  SI. 25 
FICK.     Diseases  of  the  Eye  and  Ophthalmoscopy.     Translated 

by  A.  B.  Halb,  M.D.     167  lUus.     Cloth,  $4.50;   Sheep,  $5.50 

GOULD  AND  PYLE.  Compend  of  Diseases  of  the  Eye  and  Re- 
fraction. Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulse,  Usefvil  Tables,  a 
Glossary,  and  111  Illus.,  several  of  which  are  in  colors.  2d 
Edition,  Revised.  Cloth,  $1.00;  Interleaved,  SI. 25 

GOWERS.     Ophthalmoscopy.     4th  Edition.     Illus.      In  Press. 

GREEFF.  The  Microscopic  Examination  of  the  Eye.  Illu»- 
trated.  $1.25 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illu«.  .40 

HARTRIDGE.  On  the  Ophthalmoscope.  4th  Edition.  With 
4  Colored  Plates  and  68  Wood-cuts.  $1.50 

ECARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types. 
12th  Edition,  Enlarged.  $1.60 

HANSELL  AND  SWEET.  Treatise  on  Diseases  of  the  Eye. 
With  253  Illustrations.  $4.00 

HANSELL  AND  REBER.  Muscular  Anomalies  of  the  Eye. 
Illustrated.  $1.50 

HENDERSON.     Notes  on  the  Eye.     138  Illus.     3d  Ed.        $1.50 

JENNINGS.  Manual  of  Ophthalmoscopy.  95  Illustrations  and 
1  Colored  Plate.  $1.50 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosia  and  the  Cor- 
rection of  its  Errors.     7th  Edition.  In  Press 

OHLEMANN.  Ocular  Therapeutics.  Authorized  Translation, 
and  Edited  by  Dk.  Charles  A.  Oliver.  $1.75 


MEDICAL  BOOKS  15 


PARSONS.  Elementary  Ophthalmic  Opticg.  With  Diagram- 
matic lUuBtrations  S2  00 

PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     3d  Edition.     52  Illustrations.  $1.00 

SWANZY.  Diseases  of  the  Eye  and  Their  Treatment.  8th 
Edition,  Revised  and  Enlarged.  168  Illustrations,  1  Plain 
Plate   and  a  Zephyr  Test  Card.  $2.50 

THORIKGTON.  Retinoscopy.  4th  Edition,  Carefully  Revised. 
lUustrated.  $1-00 

THORINGTON.  Refraction  and  How  to  Refract.  200  Illustra- 
tions, 13  of  which  are  colored.     2d  Edition.  $1.50 

WALKER.  Studen*'  Aid  in  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  a  Glossary.  $1.50 

WORTH.     Squint :   Its  Causes,  Pathology,  Treatment.        $2.00 

WRIGHT.  Ophthalmology.  2d  Edition,  Revised  and  Enlarged. 
117  Illustrations  and  a  Glossary.  13.00 

FEVERS. 

GOODALL  AND  WASHBOURN.     Fevers  and  Their  Treatment. 

Illustrated.  $3.00 

WILCOX.     Fever  Nixrsing.     Just  Ready.  $1.00 

GYNECOLOGY. 

BYFORD  (H.  T.l.  Manual  of  Gynecology.  3d  Edition,  Revised 
and  Enlarged.'     363  Illustrations.  $3.00;  Sheep,  $3.50 

FULLERTON,  Surgical  Nursing.  3d  Edition,  Revised  and 
Enlarged.     69  Illustrations.  $1.00 

GALABIN.  Diseases  of  Women.  Sixth  Edition.  By  Alfred 
Lewis  Galabin,  m.a.,  m.d.,  p.r.c.p.  6th  Edition,  Revised 
and  Enlarged.     284  Illustrations.     Octavo.  Cloth,  $5.00 

LEWERS.     Diseases  of  Women.     146  lilus.     5th  Ed.  $2.50 

MONTGOMERY.  Practical  Gynecology.  A  Complete  Sys- 
tematic Text-Book.  2d  Edition,  Revised  and  Enlarged. 
With  539  Illus.  Cloth,  $5.00;  Leather,  $6.00 

ROBERTS.  Gynecological  Pathology.  With  127  Full-page 
Plates  containing  151  Figures.  $6.00 

WELLS.  Compend  of  Gynecology.  145  Illustrations.  3d  Edition, 
Revised  and  Enlarged.  $1.00;  Interleaved,  $1.25 

HEART. 

THORNE.  The  Schott  Methods  of  the  Treatment  of  Chronic 
Heart  Disease.     Fourth  Edition.     Illustrated.  $2.00 

HISTOLOGY. 

GUSHING.  Compend  of  Histology.  By  H.  H.  Gubhins,  m.d., 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Phila- 
delphia.    Illus.     Nearly  Ready.  $1.00;  Interleaved,  $1.25 

LAZARUS-BARLOW.  Pathological  Anatomy  and  Histology. 
Illustrated-  *6.60 


16  SUBJECT  CATALOGUE. 

STIRLING.  Outlines  of  Practical  Histology.  368  lUustrationg. 
2d  Edition,  Revised  and  Enlarged.      With  new  Illua.         $2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
A.  ScHAPER,  M.D.,  University  of  Breslau,  formerly  Demon- 
strator of  Histology,  Harvard  Medical  School.  Fifth  Amer- 
ican from  10th  German  Edition,  Revised  and  Enlarged.  353 
Illustrations.  $3.00 

HYGIENE. 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Anti- 
•^psis.  Disinfection,  Bacteriology,  Immunity,  Heating,  Venti- 
lation, etc.  $1.25 

CONN,     Agricultural  Bacteriology.     Illustrated.  $2.50 

CONN.     Bacteriology  of  Milk  and  Milk  Products.     Illus.     $1.26 

COPLIN.  Practical  Hygiene.  A  Complete  American  Text- 
Book.     138  Illustrations.     New  Edition.  Preparing- 

HARTSHORNE.     Our  Homes.     Illustrated.  .40 

KENWOOD.  Public  Health  Laboratory  Work.  116  Illustra- 
tions and  3  Plates.  $2.00 

LEFFMANN.  Select  Methods  in  Food  Analysis.  53  Illustra- 
tions and  4  Plates.     2d  Edition.  In  Press. 

LEFFMANN.  Examination  of  Water  for  Sanitary  and  Technical 
Purposes.     5th  Edition.     Illustrated.       Just  Ready.         $1.25 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illustrated. 
Second  Edition.  $1.25 

LINCOLN.     School  and  Industrial  Hygiene.  .40 

McFARLAND.  Prophylaxis  and  Personal  Hygiene.  Car©  of 
the  Sick.     See  Cohen,  Physiologic  Therapeutics,  page  17. 

NOTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates  and 
138  other  Illustrations.     8vo.     2d  Edition.  $7.00 

PARKES  AND  KENWOOD.  Hygiene  and  Public  Health.  2d 
Edition,  Enlarged.     Illustrated.  $3.00 

ROSENAU.     Disinfection  and  Disinfectants.     Illua.  $2.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domes- 
tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
Various  Authors.     In  three  octavo  volumes.     Illustrated. 

Vol.  I,  $6.00;  Vol.  II,  $6.00;  Vol.  Ill,  $5.00 

THRESH.     Water  and  Water  SuppUes.     3d  Edition.  $2.00 

THRESH.    Examination  of  Water  and  Water  Supplies.   In  Press. 

WILSON.  Handbook  of  Hygiene  and  Sanitary  Science.  With 
Illustrations.     8th  Edition.  $3.00 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Authorized 
Translation  by  Hbnkt  Lbifmann,  m.d.,  ph.d.  $1.25 

LUNGS  AND  PLEUR.^. 

KNOPF.    Pulmonary  Tuberculosis.     Its  Modern  Prophylaxis  and 

Treatment  in  Special  Institutions  and  at  Home.    Illus.    $3.00 

STEELL.     Physical  Signs  of  Ptilmonary  Disease.     Illu«.       $1.25 


MEDICAL  BOOKS.  17 


MASSAGE.     PHYSICAL  EXERCISE. 

GULICK.  Physical  Education  by  Muscular  Exercise.  Illus- 
trated.    Just  Ready.  .75 

OSTROM.  Massage  and  the  Original  Swedish  Movements. 
Their  Application  to  Various  Diseases  of  the  Body.  A  Manual 
for  Students,  Nurses,  and  Physicians.  Fifth  Edition,  En- 
larged.    115  Illustrations,  many  of  which  are  original.     $1.00 

MITCHELL  AND  GULICK.  Mechanotherapy.  Exercise,  Ortho- 
pedics, Massage,  Ocular  Corrections,  etc  Illustrated.  See 
Cohen,  Physiologic    Therapeutics,  below.     Just  Ready. 

TREVES.     Physical  Education.     Its  Value,  Methods,  eto.        .75 


MATERIA  MEDICA  AND  THERAPEUTICS. 

BRACKEN.  Outlines  of  Materia  Medica  and  Pharmacology.  $2.75 
COBLENTZ.     The  Newer  Remedies.     Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses, 
etc.     3d  Edition,  Enlarged  and  Revised.  $1.00 

COHEN.  Physiologic  Therapeutics.  Methods  other  than  Drug- 
Giving  useful  in  the  Prevention  of  Disease  and  in  the  Treat- 
ment of  the  Sick.  Mechanotherapy,  Mental  Therapeutics, 
Suggestion,  Electrotherapy,  Climatology,  Hydrotherapy, 
Pneumatotherapy,  Prophylaxis,  Dietetics,  Organotherapy, 
Phototherapy,  Mineral  Waters,  Baths,  etc.  11  volumes,  8vo. 
Illustrated.      (Subscription.)  Cloth,  $27.50;  i  Mor.,  $38.50 

Special  Descriptive  Circular  will  be  sent  upon  application. 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition,  Revised.  $4.00 

GROFF.  Materia  Medica  for  Nurses,  with  Questions  for  Self- 
Examination.     2d  Edition,  Revised  and  Improved.  $1.25 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and  Pre- 
scription Writing.  $1.50 

HEWLETT.     Seriun-Therapy,  Vaccines,  etc.  $1.75 

POTTER.  Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics, including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and 
Formulae.  9th  Edition,  Revised  and  Enlarged.  With  Thumb 
Index  in  each  copy.  Cloth,  $5.00 ;  Sheep,  $6.00 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and  Pre- 
scription Writing,  with  Special  Reference  to  the  Physiological 
Action  of  Drugs.     6th  Edition.  $1.00;  Interleaved,  $1.25 

MURRAY.     Rough  Notes  on  Remedies.     4th  Edition.  $1.25 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Source,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Pharma- 
cal  Botany.  With  sections  on  Histology  and  Microtechniqae, 
by  W.  C.  Stbvbns.  374  Illustrations,  many  of  which  are 
original.     3d  Edition,  In  Press. 

SCOVILLE.  The  Art  of  Compounding.  3d  Edition,  Revised 
and  Enlarged.     Just  Ready.  $2.50 


18  SUBJECT  CATALOGUE. 

TAVERA.     Medicinal  Plants  of  the  Philippinei.  S2.00 

WHITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Pharma- 
cology* and  Therapeutics.  5th  American  Edition,  Revised  by 
Rbtnolb  W.  Wilcox,  m.a.,  m.d.,  ll.d..  Professor  of  Clinical 
Medicine  and  Therapeutics  at  the  New  York  Post-Graduate 
Medical  School.  Cloth,  $3.00 ;  Leather,  $3.50 

MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

REESE.  Medical  Jurisprudence  and  Toxicolojy.  A  Text-Book 
for  Medical  and  Legal  Practitioners  and  Students.  6th 
Edition.     Revised  by  Hknrt  Lbitmjlnn.  m.». 

Cloth,  $3.00 ;  Leather,  $3.50 

"To  the  student  of  medical  jurisprudence  and  toxicology  it  is 
invaluable,  as  it  is  concise,  clear,  and  thorough  in  every  respect." 
— Th«  American  Journal  of  th«  Medical  Science*. 

TANIfER.  Memoranda  of  Poisons.  Their  Antidotes  and  Tests. 
9th  Edition,  by  Dr.  Hbnrt  Lbffmakk.  .75 

MICROSCOPY. 

CARPENTER.  The  Microscope  and  Its  Revelations.  8th 
Edition,  Revised  and  Enlarged.  817  Illustrations  and  23 
Plates.  Cloth,  $8.00;  Half  Morocco,  $9.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
lUustrated.  $3.50 

LEE.  The  Microtomist's  Vade  Mecum.  A  Handbook  of 
Methods  of  Microscopical  Anatomy.  887  Articles.  5th 
Edition,  Enlarged.  $4.00 

OERTEL.  Medical  Microscopy.  A  Guide  to  Diagnosis,  Ele- 
mentary Laboratory  Methods  and  Microscopic  Technic.  131 
Illustrations.  $2.00 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bacteri- 
ology, Neoplasms,  Urinary  Examination,  etc.  Niunerous 
Illustrations,  some  of  which  are  printed  in  colors.  $2.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the 
Microscope  in  Practical  Medicine.     100  Illustrations.        $2.00 

MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  $4.00 

BUXTON.     Anesthetics.     Illustrated.     3d  Edition.  $1.50 

COHEN.     Organotherapy.    See  Cohen,  Physiologic  Therapeutict, 

■page  17. 

FRENKEL.     Tabetic  Ataxia.     Illustrated.  $3.00 

GOULD.  Borderland  Studies.  Miscellaneous  Essays.  12mo.  $2.00 

GOULD.      Biographic  Clinics.      Volume  I.      The  Origin  of  the 

Ill-Health    of    DeQuincy,     Carlyle,    Darwin,     Huxley,    and 

Browning.  $1.00 

GOULD      Biographic  Clinics.     Volume  II.     The  Origin  of  the 

Ill-Health    of    Wagner,    Parkman,    Mrs.    Carlisle,    Spencer, 

Whittier,  Ossoli,  George  Eliot,  andNietsche.  §1.00 


MEDICAL  BOOKS.  1» 


GREENE.     Medical    Examination    for    Life    Insiirance.     IUub. 
With  colored  and  other  Engravings.     2d  Edition.       In  Prest. 
HAIO.     Causation  of  Disease  by  Uric  Acid.     The  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Gout,  Rheuma- 
tism, Diabetes,  Bright'a  Disease,  etc.     6th  Edition.         $3.50 
HENRY.     A  Practical  Treatise  on  Anemia.  Half  Cloth,  .50 

OSGOOD.     The  "Winter  and  Its  Dangers.  .40 

OSLER.     Essays  and  Addresses.  In  Press. 

PACKARD.     Sea  Air  and  Sea  Bathing.  .40 

RICHARDSON.     Long  Life  and  How  to  Reach  It.  .40 

ST.  CLAIR.    Compend  of  Medical  Latin.    2d  Edition.    In  Press. 
SCHEUBE.     Diseases  of  Warm  Countries.     Illustrated.     $8.00 

TISSIER.  Pneumotherapy.  Aerotherapy,  Inhalation  Methods. 
See  Cohen,    Physiologic  ThtrapetUics,  page  17. 

TURNBULL.     Artificial  Anesthesia.     4th  Ed.     Illus.  $2.50 

WARDEN.     The  Paris  Medical  School.  Paper,  .75 

WEBER  AND  HINSDALE.     Climatology  and  Health  Resorts. 
Including  Mineral  Springs.     2  yoIs.     Illustrated  with  Colored 
Maps.     See  Cohen,  Physiologic  Therapeutics,  page  17. 
WILSON.     The  Summer  and  Its  Diseases.  .40 

WINTERNITZ.  Hydrotherapy,  Thermotherapy,  Phototherapy, 
Mineral  Waters,  Baths,  etc.  Illustrated.  See  Cohen,  Physio- 
logic Therapeutics,  page  17. 

NERVOUS  DISEASES. 

DERCUM.  Rest,  Suggestion,  Mental  Therapeutics.  See  Cohen, 
Physiologic  TherapetUics,  page  17. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central 
Nervous  System.  With  271  original  colored  and  other  Illus- 
trations. Cloth,  $6.00;  Sheep,  $7.00 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

GOWERS.     Manual   of   Diseases   of   the    Nervous   System.     A 
Complete  Text-Book.     Revised,  Enlarged,  and  in  many  parts 
Rewritten.     With  many  new  Illustrations.     Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.     3d  Edition, 
Enlarged.  Cloth,  $4.00;  Sheep,  $5.00 

Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves ;  General  and 
Functional  Disease.     2d  Ed.         Cloth,  $4.00;  Sheep,  $5.00 

GOWERS.  Epilepsy  and  Other  Chronic  Convulsive  Diseases. 
2d  Edition.  $3.00 

GOWERS.  Clinical  Lectures.  Illustrated.  Second  Series. 
Just  Ready.  $2.00 

HORSLEY.  The  Brain  and  Spmal  Cord,  the  Structure  and 
Functions  of.     Numerous  Illuatrations.  $2.50 

ORMEROD.  Diseases  of  the  Nervous  System.  86  Wood  En- 
gravings. $1.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases.  Illus- 
trated. $1.25 

PRESTON.  Hysteria  and  Certain  Allied  Conditions.  Their 
Nature  and  Treatment.     Illustrated.  $2.00 

WOOD.     Brain  Work  and  Overwork.  .46 


20  SUBJECT  CATALOQUK 

NURSING  (see  also  Massage). 

Special  Catalogue  of  Books  for  Nursee  tent  free  upon  application. 

CAJfFIELD.  Hygiene  of  the  Sick-Room.  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Anti- 
sepsis, Disinfection,  Bacteriology,  Immunity,  Heating  and 
Ventilation,  and  Kindred  Subjects  for  the  Use  of  Nurses  and 
Other  Intelligent  Women.  $1.25 

CUFF.     Lecttires  to  Nurses  on  Medicine.     4th  Edition.        $1.25 

DAVIS.     Bandaging.    Its  Principles  and  Practice.     163  Original 

Illustrations.  $1.50 

FULLERTON.     Obstetric  Ntirsing.     6th  Ed.   45   lUus.         $1.00 

FULLERTON.     Surgical  Nursing.     3d  Ed.     69  lUus.  $1.00 

GROFF.     Materia  Medica  for  Nurses.     With  Questions  for  Self- 

Examination.     2d    Edition,    Revised  and   Improved      $1.25 

HADLEY.  General,  Medical,  and  Surgical  Nursing.  A  very 
Ciomplet©  Manual,  Including  Sick-room  Cookery.  $1.25 

HUMPHREY.  A  Manual  for  Nurses.  Including  General 
Anatomy  and  Physiology,  Management  of  the  Sick-room,  etc. 
24th  Edition.     79  lUustrations.  $1.00 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domes- 
tic Management  of  the  Ordinary  Emergencies  of  Early  Life, 
Massage,  etc.     6th  Edition.     25  Illustrations.  $1.00 

TEMPERATURE  AND  CLINICAL  CHARTS.     See  page  25. 
VOSWINKEL.     Surgical  Nursing.     Second   Edition,   Enlarged. 
112  Illustrations.  $1.00 

WILCOX.     Fever  Nursing.     Just  Ready.  $1.00 

OBSTETRICS. 

EDGAR.  Text-Book  of  Obstetrics.  By  J.  Clitton  Edgar, 
M.D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Medical 
Department  of  Cornell  University,  New  York  City,  etc.  1221 
Illustrations.    Just  Ready.  Cloth,  $6.00;  Sheep,  $7.00 

FULLERTON,     Obstetric  Nursing.     6th  Ed.     Illus.  $1.00 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by 
Wm.  H.  Wblls.  M.D.,  Demonstrator  of  Clinical  Obstetrics, 
Jefferson  Medical  College.  62  Illus.  $1.00;  Interleaved,  SI. 25 

WINCKEL.  Text-Book  of  Obstetrics,  Including  the  Pathology 
and  Therapeutics  of  the  Puerperal  State.     Illustrated.      $5.00 

PATHOLOGY. 

DANIEL.  Laboratory  Exercises  in  Tropical  Medicine.  Just 
Ready.  S4.00 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed 
for  the  Use  of  Hospitals  for  the  Insane  and  other  Public  Insti- 
tutions.    Ten  full-page  Plates  and  other  Illustrations.     $1.25 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Tech  - 
nic  of  Post-Mortems,  Methods  of  Pathologic  Research,  etc. 
330  Illustrations,  7  Colored  Plates.     3d  Edition.  $3.60 


MEDICAL  BOOKS.  21 


DA  COSTA.  Clinical  Hematology.  A  Practical  Guide  to  the 
Examination  of  the  Blood.  Six  Colored  Plates  and  48  Illus- 
trations. Cloth,  $5.00 ;  Sheep,  $6.00 

LAZARUS-BARLOW.  Pathological  Anatomy.  With  7  Colored 
Plates  and  171  other  Illustrations.  $6.50 

LAZARUS-BARLOW.  General  or  Experimental  Pathology. 
Illustrated.     2d  Edition.     Just  Ready.  $6.50 

MacLEOD.  The  Pathology  of  the  Skin,  Colored  and  other 
Illustrations.  „      ,      $5.00 

MARTIN.    Manual  of  Pathology.   Illustrated.   Just  Ready.  $4.00 

ROBERTS.     Gimecological  Pathology.     Illustrated.  $6.00 

THAYER.     Compend  of  Special  Pathology.     Illustrated. 

$1.00;  Interleaved,  $1.25 

THAYER.     Manual    of  General    and   Special    Pathology.     131 

Illustrations.     711  pages.    2d  Edition.     Full  Limp  Morocco, 

Gilt  Edges,  Round  Corners.  $2.50 

VIRCHOW.     Post-Mortem  Examinations.     3d  Edition.  .75 

WHITACRE.     Laboratory  Text-Book  of  Pathology.     With  121 

Illustrations.  $1.50 

PHARMACY. 

Special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book  by 
the  Professor  in  the  New  York  College  of  Pharmacy.  2d  Ed., 
Revised  and  Enlarged.     437  lUus.     Cloth,  $3.50;  Sheep,  $4.50 

COBLENTZ.     Volumetric  Analysis.     Illustrated.  $1.25 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — Eng- 
lish, French,  and  American.  A  Compendious  History  of  the 
Materia  Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Es- 
tablished Preparations,  an  Index  of  Diseases  and  their  Reme- 
dies.    7th  Edition.  $2.00 

BEASLEY.  Druggists'  General  Receipt  Book.  Comprising  a 
Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Pro- 
prietary Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and 
Cosmetics,  Beverages,  Dietetic  Articles  and  Condiments,  Trade 
Chemicals,  Scientific  Processes,  and  many  Useful  Tables. 
10th  Edition.  $2.00 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopoeias. 
Comprising  Standard  and  Approved  Formulae  for  the  Prepara- 
tions and  Compounds  Employed  in  Medicine.    12th  Ed.  $2.00 

GREENISH.  Microscopical  Examination  of  Foods  and  Drugs. 
Illustrated.  $3.50 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine.  4th 
Edition.     With  elaborate  Vocabularies.     Just  Ready.     $1.60 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the 
Vegetable  and  Animal  Drugs.  Comprising  the  Botanical  and 
Physical  Characteristics,  Sovirce,  Constituents,  and  Pharma- 
copeial  Preparations,  Insects  Injurious  to  Drugs,  and  Phar- 
macal  Botany.  With  sections  on  Histology  and  Microtech- 
nique, by  W.  C.  Stbvbn».     374  Illustrations.    Third  Edition. 

In  Press. 


22  SUBJECT  CATALOGUE. 

SCOVILLE.  The  Art  of  Compounding.  Third  Edition,  Re- 
vised and  Enlarged.     Just  Ready.  Cloth,  $2.50 

STEWART.  Compend  of  Pharmacy,  Based  upon  "Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in 
Accordance  with  the  U.  S.  Pharmacopoeia,  1890.  Complete 
Tables  of  Metric  and  English  Weights  and  Measures. 

$1.00;  Interleaved,  S1.2o 

TAVERA.     Medicinal  Plants  of  the  Philippines.  $2.00 

UNITED  STATES  PHARMACOPCEIA.  7th  Decennial  Revision. 
Cloth,  $2.50  (postpaid,  $2.77) ;  Sheep,  $3.00  (postpaid,  $3.27) ; 
Interleaved,  $4.00  (postpaid,  $4.50) ;  Printed  on  one  side  of 
page  only,  unbound,  $3.50  (postpaid,  $3.90). 
Select  Tables  from  the  U.  S.  P.  Being  Nine  of  the  Most  Impor- 
tant and  Useful  Tables,  Printed  on  Separate  Sheets.         .25 

POTTER.  Handbook  of  Materia  Medica,  Pharmacy,  and  Thera- 
peutics.    600  Prescriptions.     9th  Edition. 

Cloth,  $5.00:  Sheep,  $6.00 


PHYSIOLOGY. 

BIRCH.     Practical   Physiology.     An    Elementary   Class   Book. 

62  Illustrations.  $1.75 

BRUBAKER.  Text-Book  of  Physiology.  HIus.  Nearly  Ready. 
BRUBAKER,     Compend  of  Physiology.     11th  Edition,  ReAosed 

and  Enlarged.     Illustrated.  $1.00;  Interleaved,  SI. 25 

JONES.     Outlines  of  Physiology.     96  Illustrations.  $1.50 

KIRKES.  Handbook  of  Physiology.  17th  Authorized  Edition. 
Revised,  Rearranged,  and  Enlarged.  By  Phof.  W.  D.  Halli- 
burton, of  Kings  College,  London.  681  Illustrations,  some  of 
which  are  in  colors.  Cloth,  $3.00 ;  Leather,  $3.75 

LANDOIS.  A  Text-Book  of  Human  Physiology.  Including 
Histology''  and  Microscopical  Anatomy,  with  Special  Reference 
to  the  Requirements  of  Practical  Medicine.  5th  American, 
translated  and  edited  from  the  last  German  Edition  by  A.  P. 
Brubaker,  M.D.,  and  A.  A.  Eshner,  M.D^.  In  Press. 

STARLING.    Elements  of  Human  Physiology.     100  Illus.    $1.00 

STIRLING.  Outlines  of  Practical  Physiology.  Including  Chem- 
ical and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.        $2.00 

TYSON.     Cell  Doctrine.     Its  History  and  Present  State.     $1.50 


PRACTICE. 

COHEN.     Physiologic  Therapeutics.     The  Treatment  of  Disease 
by  Methods  other  than  Drug-giving.     See  page  17. 

FAGGE.     Practice  of  Medicine.     4th  Edition,  by  P.  H.  Ptb- 
Smith,  m.d.     2  volumes.  Vol.  I,  $6.00;  Vol.  II,  $6.00 

FOWLER.     Dictionary    of     Practical     Medicine.     By    various 
writers.     An  Encyclopaedia  of  Medicine. 

Cloth,  $3.00;  Half  Morocco,  $4.00 


MEDICAL  BOOKS.  28 


GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  A  Concise  Reference  Handbook,  with  particular 
Reference  to  Diagnosia  and  Treatment.  Edited  by  Drs. 
GouiiD  and  Ptlb,  Assisted  by  72  Special  Contributors.  Illus- 
trated, one  volume.  Large  Square  Octavo,  Uniform  with 
"Gould's  Illustrated  Dictionary." 

Sheep  or  Half  Mor.,  $10.00;  with  Thumb  Index,  $11.00 
Half  Rueaia,  Thumb  Index,  $12.00 
4^"  Complete  descriptive  circular  free  upon  application. 
GOULD  AND  PYLE'S  Pocket  Cyclopedia  of  Medicine  and  Sur- 
gery.    Based  upon  the  above  and  Uniform  with   "Gould's 
Pocket  Dictionary."     Full  Limp  Leather,  Gilt  Edges,  Round 
Corners,  $1.00;  with  Thumb  Index,  $1.25. 
HUGHES.     Compend  of  the  Practice  of  Medicine.     6th  Edition, 
Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Disease 
of  the  Stomach,  Intestines,  Peritoneum,  BUiary  Passages, 
Liver,  Kidneys,  etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,   Circulatory 
System,  and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  $1.00;  Interleaved,  $1.25 
Physician's  Edition.     In  one  volume,  including  the  above  two 
parts,  a  Section  on  Skin  Diseases,  and  an  Index.     6th  Re- 
vised Edition.     625  pp.     Full  Morocco,  Gilt  Edge,   12.25 
TAYLOR.     Practice  of  Medicine.     6th  Edition.  $4.00 

TYSON.     The  Practice  of  Medicine.     By  Jauibb   Ttson,  m.u  , 
Professor  of  Medicine  in  the  University  of  Pennsylvania. 
Complete  Systematic  Text-book,  with  Speeial  Reference  to 
Diagnosis  and  Treatment.     3d  Edition,  Enlarged  and  Revised. 
Colored  Plates  and  125  other  Illustrations. 

Cloth,  $5.50;  Leather,  $6.50 

STOMACH.     INTESTINES. 

FENWICK.     Cancer  of  the  Stomach.     Just  Ready.  S3.00 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Pathol- 
ogy, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy, 
Anailysis  of  Stomach  Contents,  Dietetics.  Surgery  of  the  Stom- 
ach, etc.  3d  Edition,  Revised.  With  15  Plates  and  41  other 
Illustrations,  a  number  of  which  are  in  colors. 

Cloth,  $6.00;  Sheep,  $7.00 
HEMMETER.  Diseases  of  the  Intestines.  Their  Special  Path- 
ology, Diagnosis,  and  Treatment.  With  Sections  on  Anatomy 
and  Physiology,  Microscopic  and  Chemic  Examination  of  In- 
testinal Contents,  Secretions,  Feces  and  Urine,  Intestinal 
Bacteria  and  Parasites,  Surgery  of  the  Intestines,  Dietetics, 
Diseases  of  the  Rectum,  etc.  With  Full-page  Colored  Plates 
and  many  other  Original  Illustrations.  2  volumes.  Octavo. 
Price  of  each  volume,  Cloth,  $5.00;  Sheep,  $6.00 

SKIN. 

BULKLEY.     The  Skin  in  Health  and  Disease.    Illustrated.     .40 
CROCKER.     Diseases  of  the  Skin.     Their  Dewription,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the 
Skin  Eruptions  of  Children.     3d  Edition,  Thoroughly  Re-vised. 
With  New  Illustrations.  Cloth,  S5.00;  Sheep,  $6.00 

MacLEOD.  The  Pathology  of  the  Skin.  Colored  and  other 
Illustrations.  85.00 


S4  SUBJECT  CATALOGUE. 

SCHAMBERG.  Diseases  of  the  Skin.  3d  Edition,  Revised  and 
Enlarged.     106  Illustrations.    Cloth,  $1.00;  Interleaved,  $1.25 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diamosis  and  Treatment,  with  Special  Reference  to  Differ- 
ential Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With 
FormulsB  and  60  Illustrations,  some  of  which  are  printed  in 
colors.  $2.75 

SURGERY  AND  SURGICAL  DISEASES 
(see  also  Urinary  Organs). 

BERRY.     Diseases  of  the  Thyroid  Gland.     Illustrated.       S4.00 
BERRY.     Surgical  Diagnosis.  In  Press. 

BINNIE.     Operative  Surgery.     Illustrated.  Preparing. 

BURRELL  AND  BLAKE.  Case  Teaching  in  Siirgery.  Just 
Ready.  .75 

BUTLIN.  Operative  Surgery  of  Malignant  Disease.  2d  Edi- 
tion.    Illustrated.     Octavo.  $4.50 

CASPER  AND  RICHTER.     Functional  Kidney  Diagnosis.  $1.50 

DAVIS.  Bandaging.  Its  Principles  and  Practice.  163  Original 
Illustrations.  $1.50 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Human  Anatomy 
in  its  Application  to  Medicine  and  Surgery.  With  about  500 
very  handsome  full-page  Illustrations  Engraved  from  Original 
Drawings  made  by  special  Artists  from  Dissections  prepared 
for  the  purpose.  Three  volumes.  Royal  Square  Octavo. 
By  Subscription  only.     Now  Ready. 

Half  Morocco  or  Sheep,  $30.00;  Half  Russia,  $33.00 

DEAVER.  Appendicitis :  its  Sjrmptoms,  Diagnosis,  Pathology, 
Treatment,  and  CompUcations.  Elaborately  Illustrated  with 
Colored  Plates  and  other  Illus.     3d  Edition.       Nearly  Ready 

DOUGLAS.  Stirgical  Diseases  of  the  Abdomen.  Illustrated 
by  20  Full-page  Plates.  Cloth,  $7.00;   Sheep,  $8.00 

DULLES.  What  to  do  First  in  Accidents  and  Poisoning.  5th 
Edition.     New  Illustrations.  $1.00 

FULLERTON.     Surgical  Nursing.     3d  Ed.     69  lUus.  $1.00 

HAMILTON.     Lectures  on  Tumors.     3d  Edition.  $1.25 

HEATH.     Minor  Surgery  and  Bandaging.     12th  Edition,   Re- 

rise-d  £nd  Enlarged.   195  Illus.,  Formulae,  Diet  List,  etc.  $1.50 

HEATH .     Clinical  Lectures  on  Surgical  Subjects.  $2.00 

HORWITZ.     Compend    of    Surgery    and  Bandaging.    Including 

Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical 

Diseases,  etc.,  with  Differential  Diagnosis  and  Treatment.    5th 

Edition,  very  much  Enlarged  and  Rearranged.      167  Illus.,  98 

Formulae.  Cloth,  $1.00;  Interleaved,  SI. 25 

JACOBSON.     Operations  of  Surgery.     4th  Ed.,  Enlarged.     550 

Illus.     Two  volumes.  Cloth,  $10.00;  Leather,  $12.00 

KEAY.     Medical  Treatment  of  Gail-Stones.  $1.25 

K£HR.     Gall-stone  Disease.     Translated  by  Whxiam  Wotktnb 

Sbtmous,  u.d.  $2.50 

MAKINS.     Surgical  Experiences  in  South  Africa-     1899-1900. 

lUustrated.  $4.00 

MAYLARD.     Surgery  of  the  Alimentary  Canal.     97  Illustrations. 

2d  Edition,  Revised.  $3.00 


MEDICAL  BOOKS.  26 


MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by 
John  B.  Hamilton,  m.».,  ll.d.,  Professor  of  the  Principles  of 
Surgery  and  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
623  Illustrations,  many  of  which  are  printed  in  colors. 

Cloth,  $6.00;  Leather,  $7.00 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Revised  and 
Enlarged.     Ill  Illustrations.  $1.00 

WALSHAM.  Manual  of  Practical  Surgery.  8th  Ed..  Revised 
and  Enlarged.  622  Engravings  and  20  Skiagrams.  1227 
pages.  $4.50 


TEMPERATURE  CHARTS,  ETC. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Tempera- 
ture, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex,  Occu- 
pation, Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  50  cts.  Price  to 
Hospitals,  500  copies,  $4.00;  1000  copies,  S7.50. 

KEEN'S  Clinical  Charts.  Seven  Outline  Drawings  of  the  Body 
on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Each  Drawing  may  be  had  separately, 
twenty-five  to  pad,  25  cents. 


THROAT  AND  NOSE  (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.     Diseases  of  the  Nose  and  Throat.     2d  Edition,  Enlarged. 
Two  Colored  Plates  and  80  Illustrations.  $2.75 

HOLLOPETER.     Hay  Fever.     Its  Successful  Treatment.    $1.00 

KNIGHT.     Diseases  of  the  Throat.     A  Manual  for  Students. 
Illustrated.     Just  Ready.  $3.00 

KYLE  (J.  J.),     Diseases  of  the  Ear,  Nose,  and  Throat.     A  Com- 
pend  for  Students.     Illustrated.       $1.00;  Interleaved,  $1.25 

McBRIDE.     Diseases  of  the  Throat,  Nose,  and  Ear.     With  Col- 
ored Illustrations  from  Original  Drawings.     3d  Ed.         $7.00 

POTTER-     Speech  and  its  Defects.     Considered  Physiologically, 
Pathologically,  and  Remedially.  $1.00 


URINE  AND  URINARY  ORGANS. 

CASPER  AND  RICHTER.   Functional  Kjdney  Diagnosis.    $1.50 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Micro- 
scopical, for  Laboratory  Use.  Illustrated  and  Interleaved. 
6th  Edition.  $1.00 

KLEEN.     Diabetes  and  Glycosuria.  $2.50 


26  SUBJECT  CATALOGUE. 

MEMMINGER.  Diagnosis  by  the  Urine.  2d  Edition.  24  Illus- 
trations. $1.00 

MORRIS.  Renal  Surgery,  with  Special  Reference  to  Stone  in  the 
Kidney  and  Ureter  and  to  the  Surgical  Treatment  of  Calculous 
Anuria.     Illustrated.  $2.00 

MOULLIN.  Enlargement  of  the  Prostate.  Its  Treatment  and 
Radical  Cure.     3d  Edition.     Illustrated.  In  Press. 

MOULLIN.  Inflammation  of  the  Bladder  and  Urinary  Fever. 
Octavo.  $1.50 

TYSON.  Bright's  Disease  and  Diabetes.  Including  Articles  on 
Ocular  Manifestations  by  Prof.  G.  E.  de  Schweinitz. 
Colored  Plates  and  other  Illustrations.    2d  Edition.    In  Press. 

TYSON.  Guide  to  Examination  of  the  Urine.  For  the  Use  of 
Physicians  and  Students.  With  Colored  Plate  and  Numerous 
Illustrations  engraved  on  wood.  10th  Edition,  Revised,  En- 
larged, and  partly  Rewritten.  With  New  Uliistrations.  Just 
Ready.  $1.50 

VAN  NUYS.     Chemical  Analysis  of  Urine.     39  Illus.  $1.00 

VENEREAL  DISEASES. 

GOWERS.     Syphilis  and  the  Nervous  System.  $1.00 

STURGIS  AND  CABOT.     Student's  Manual  of  Venereal  Diseases. 

7th  Revised  and  Enlarged  Edition.     12mo  $1.25 

VETERINARY. 

BALLOU.  Eqxiine  Anatomy  and  Physiology.  29  Graphic 
Illustrations.  $1.00;  Interleaved,  S1.25 


JACOBSON.  The  Operations  of  Surgery.  By 
W.  H.  A.  Jacobson,  F.R.C.S.,  Surgeon  to 
Guy's  Hospital ;  Consulting  Surgeon  Royal 
Hospital  for  Children  and  Women ;  and  F. 
J.  Steward,  f.r.c.s.,  Assistant  Surgeon 
Guy's  Hospital.  Fourth  Edition — Revised, 
Enlarged,  and  Improved.  550  Illustrations. 
Two  Volumes,  Octavo,  1524  pages. 

Cloth,  $10.00;  Sheep,  $12.00 

"  The  important  anatomical  points  are  clearly  set  forth,  the 
conditions  indicating  or  contraindicating  operative  interference 
are  given,  the  details  of  the  operations  themselves  are  brought 
forward  prominently,  and  frequently  the  after-treatment  is 
considered.  Herein  is  one  of  the  strong  points  of  the  book." — 
New  York  Medical  Journal, 


"We  know  of  no  aeries  of  books  issued  by  any  house  that  so 
fullv  meets  our  approval  aa  these  ?  Quia-Compends?.  They  are 
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POTTER.  HUMAN  ANATOMY.  Seventh  Edition.  138  Illus- 
trations and  16  Plates  of  Nerves  and  Arteries. 

HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  SisthEdition, 
Enlarged  and  Improved. 

HUGHES.  PRACTICE  OF  MEDICINE.  PartU.  Sixth  Edition, 
Revised  and  Improved. 

BRUBAKER.     PHYSIOLOGY.     Eleventh  Edition.    Illus. 

LANDIS.     OBSTETRICS.     Seventh    Edition.     52    Illus. 

POTTER.  MATERIA  MEDICA,  THERAPEUTICS,  AND  PRE- 
SCRIPTION WRITING.     Sixth  Revised  Edition. 

WELLS.     GYNECOLOGY.     Thurd  Edition.     145  Illus. 

GOULD  AND  PYLE.  DISEASES  OF  THE  EYE.  Second  Edi- 
tion.    Refraction,  Treatment,  Siirgery,  etc.     109  Illus. 

HORWITZ.  SURGERY.  Including  Minor  Surgery,  Bandaging, 
Surgical  Diseases,  Differential  Diagnosis  and  Treatment. 
Fifth  Edition.  With  98  Formulas  and  71  Illustrations. 

LEFFMANN.  MEDICAL  CHEMISTRY.  Fourth  Edition.  In- 
cluding Urinalysis,  Animal  Chemistry,  Chemistry  of  Milk, 
Blood,  Tissues,  the  Secretions,  etc. 

STEWART.  PHARMACY.  Fifth  Edition.  Based  upon  Prof. 
Remington's  Text-Book  of  Pharmacy. 

BALLOU.  EQUINE  ANATOMY  AND  PHYSIOLOGY.  29  graphic 
Illustrations. 

WARREN.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE. 
Fourth  Edition,  lUtistrated. 

HATFIELD.     DISEASES  OF  CHILDREN.     3d  Edition. 

ST.  CLAIR.     Medical  Latin.     2d  Edition.  In  Press. 

SCHAMBERG.  DISEASES  OF  THE  SKIN.  Third  Edition, 
Revised  and  Enlarged.     106  Illustrations. 

GUSHING.     HISTOLOGY.     lUustrated.  In  Press. 

THAYER.     SPECIAL  PATHOLOGY.     34  Illustrations 

KYLE.  DISEASES  OF  THE  EAR,  NOSE,  AND  THROAT. 
85  Illustrations. 

27 


DA  COSTA 


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A  Practical  Guide  to  the  Examination  of  the  Blood  by 
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*^*  A  new,  thorough,  systematic,  and  comprehensive 
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THAYER 


Manual   of  Pathology 

GENERAL  AND  SPECIAL 

Second  Edition.  131  Illustrations.  711  Pages. 
1 2  mo.  Full  Limp  Morocco,  Gilt  Edges, 
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This  book  shows  evidence  of  clinical  as  well  as  pathologi- 
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28 


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eaicme   ana   durge 


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39 


A  NEW  EDITION 


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The  Diseases  of  the  Skin.  Their  Description,  Pathology, 
Diagnosis,  and  Treatment,  with  Special  Reference  to  the 
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By  F.  R.  Sturgis,  M.d.,  Sometime  Clinical  Professor  of 
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versity of  the  City  of  New  York.  Seventh  Edition,  Revised 
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30 


FOR  THE  DISSECTING  ROOM 

Holden*s  Anatomy — Seventh  Edition 
320  Illustrations 

A  Manual  of  the  Dissections  of  the  Human  Body.  By  John 
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31 


EDGAR'S    , 

OBSTETRICS 

A   NEW   TEXT -BOOK 
1 2  2 1    Illustrations 


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details,  and  in  the  number 
and  usefulness  of  its  illus- 
trations.     See  page  20. 


OCTAVO.      CLOTH,   $6,005    SHEEP,   $7.00 


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